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CUfllumbta  Hmn^rsttg 
in  X\\t  Oltty  of  Nrm  fork 


S^fj^r^nr^  IGtbrarg 


TREATISE 


ON 


ORTHOPEDIC  SURGERY 

BY 

EDATAED  H.  BRADFORD.  M.D. 

Surgeon  to  the  Boston  Children's  Hospital ;  Consulting  Surgeon  to  the  Boston  City 
Hospital;  Professor  Orthopedic  Surgery,  Harvard  JJedical  School 

AXD 

ROBERT  ^\,  LOYETT.  M.D. 

Surgeon  to  the  Infants'  Hospital  and  to  the  Peabody  Home  for  Crippled  Children; 

Assistant  Surgeon  to  the  Boston  Children's  Hospital ;  Assistant  in 

Orthopedic  Surgery,  Harvard  Medical  School 


THIRD   EDITION 

ILLUSTRATED  BY   FIVE  HUNDEED  AND 
NINETY-TWO  ENGRAVINGS 


NEW     YORK 
WILLIAM    WOOD    AND    COMPANY 

MDCCCCVII 


.J)    i 


Copyright,   1905, 
By   WILLIAM   WOOD   AND    COMPANY 


)l^)bll  i- 


TO 

Cbarles  TKIlilliam  leUot 

PRESIDENT   OF  HARVARD  UNIVERSITY,   THIS  BOOK 

IS  DEDICATED.       .IX  EXPRESSION  OF  RESPECT  FOR 

THE  MOST   STi:in:LATIXG  OF   EDUCATORS. 


PREFACE  TO  THE  THIRD  EDITION. 


In  preparing  the  third  edition  of  this  work  it  has  been  necessary  to 
rewrite  entirely  several  portions,  to  make  extensive  alterations  in  others, 
and  to  rearrange  chapters  and  subjects.  These  changes  have  been 
made  in  the  endeavor  to  offer  to  the  reader  a  description  of  the  present 
condition  of  orthopedic  surgery  with  its  notable  progress  since  the  pub- 
lication of  the  second  edition  in  1 899. 

The  most  marked  difference  between  the  second  and  third  editions 
will  be  found  in  the  chapters  treating  of  congenital  dislocation  of  the 
hip,  of  scoliosis,  of  traumatic  and  non-traumatic  coxa  vara,  and  of  non- 
tuberculous  diseases  of  the  joints,  as  it  is  in  the  study  of  these  subjects 
that  the  greatest  advances  have  been  made.  Many  original  illustra- 
tions have  been  added  and  many  of  the  old  ones  have  been  improved, 
making  them  more  illustrative  of  the  subjects  mentioned  in  the  text. 

A  chapter  giving  the  details  of  orthopedic  apparatus,  with  descrip- 
tions and  drawings  of  appliances  found  to  be  of  practical  efficiency,  is 
added  in  the  hope  of  giving  to  the  general  practitioner  technical  infor- 
mation which  is  of  use  in  the  treatment  of  orthopedic  affections. 

The  authors  are  greatly  indebted  to  friends  and  colleagues  for  many 
helpful  suggestions  and  for  their  ready  permission  to  make  use  of  their 
illustrations  and  clinical  material. 

Boston,  April  ist,  1905. 


Digitized  by  tine  Internet  Archive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseonorthopOObrad 


CONTENTS 

CHAPTER  I. 

PAGE 

Tuberculous  Disease  of  the  Joints, i 

CHAPTER  n. 

Tuberculous  Disease  of  the  Spine, i6 

CHAPTER  in. 
Tuberculous  Disease  of  the  Hip, 84 

CHAPTER  IV. 
Tuberculous  Disease  of  the  Knee, 147 

CHAPTER  V. 

Tuberculous  Disease  of  the  Ankle  and  other  Joints,  .        .171 

CHAPTER  \  I. 

Infectious  Osteomyelitis — Infectious  Synoxttis  and  Arthritis,    .  186 

CHAPTER  Vn. 

Arthritis  Deformans, 196 

CHAPTER  VIII. 

Other  Affections  of  the  Bones  and  Joints, 224 

CHAPTER  IX. 

Rickets,  Knock-knee,  and  Bow-legs,  .        .        .        .        .        .  271 

CHAPTER  X. 

Coxa  \'ara  and  Coxa  \\alga, 30S 

CHAPTER  XL 

Lateral  Curvature  of  the  Spine,   .    .    .    .   .    .    .322 

V 


vi  CONTENTS. 

PAGE 

CHAPTER  XII. 
Other  DEFORmTiES  of  the  Spine  and  Thorax,         ,        .        .        -375 

CHAPTER  XIII. 
Torticollis, 392 

CHAPTER  XIV. 

Anterior  Poliomyelitis, 406 

CHAPTER  XV. 

Spastic  and  other  Paralyses, .  445 

CHAPTER  XVI. 

Functional  Affections  of  the  Joints, 467 

CHAPTER  XVII. 

Unilateral  Atrophy  and  Hypertrophy, 476 

CHAPTER  XVIII. 

Congenital  Dislocations, 479 

CHAPTER  XIX. 
Talipes, 518 

CHAPTER  XX. 

Flat-Foot  and  Other  Deformities  of  the  Foot,      •        .        .        .  559 

CHAPTER  XXI. 

Practical  Details  of  Apparatus, 601 


ORTHOPEDIC    SURGERY. 

CHAPTER    I. 
TUBERCULOUS    DISEASE    OF    THE   JOINTS. 

Pathology. — Etiology.— Prognosis. — Principles  of  Treatment. 

Orthopedic  surgery  deals  with  the  prevention  and  correction  of 
deformity,  and  demands  not  only  a  study  of  the  deformities  of  the  hu- 
man body,  but  also  some  knowledge  of  the  affections  which  produce 
them.  Of  these  the  most  important  are  the  tuberculous  diseases  of 
the  joints. 

Bone  tuberculosis  has  been  called  strumous,  scrofulous,  and  fungus 
disease,  caries  of  bone,  etc.,  and  various  theories  as  to  the  predisposing 
cause  have  been  presented.  It  is  known  to  be  the  result  of  the  inva- 
sion of  the  tubercle  bacillus,  which  frequently  finds  a  favorable  soil  for 
development  in  the  spongy  bone  of  the  growing  epiphyses. 

PATHOLOGY. 

Articular  tuberculosis  begins  as  an  affection  of  the  spongy  tissue  of 
the  epiphysis,  generally  near  its  line  of  junction  with  the  shaft,  occa- 
sionally near  the  articular  cartilage.  It  occurs  usually  as  a  localized 
disease,  appearing  in  one  or  more  distinct  foci;  a  simultaneous  tuber- 
culous infiltration  of  the  whole  epiphysis,  however,  rarely  happens. 

The  common  form  of  tuberculous  infection  of  the  epiphysis  is  the 
one  spoken  of  as  focal  or  encysted,  when  the  first  change  is  the  forma- 
tion of  single  or  multiple  foci  of  tuberculous  degeneration.  On  section 
of  the  diseased  epiphysis  the  first  noticeable  change  consists  in  a  local 
hypersemia  of  some  part  of  the  spongy  tissue.  There  then  appears  in 
this  hypersemic  area  a  small,  grayish,  translucent  spot,  almost  as  small 
as  one  can  see,  which  grows  more  gray  and  increases  in  size,  while  a 
zone  of  hyperaemic  tissue  develops  around  it  and  the  neighboring  bone 
looks  boggy  from  an  excess  of  the  transuded  fluid.  At  first  usually 
there  is  no  synovitis ;  it  is  purely  a  localized  ostitis. 

The  tubercle  bacilli,  being  lodged  in  the  marrow  of  the  bone,  cause 
a  multiplication  of  the  surrounding  cells,  probably  by  the  action  of  a 
toxin,  and  a  typical  tubercle  is  formed.  Such  an  area  consists  of  a  cen- 
tral mass  of  giant  and  epithelioid  cells  surrounded  by  a  zone  of  lym- 


ORTHOPEDIC  SURGERY. 


phoid  cells.  As  the  tuberculous  area  increases  by  multiplication  of 
the  cells,  the  centre  degenerates,  forming  a  necrotic  mass  in  which  fat 
drops  may  be  seen.  Sometimes  the  tubercle  bacillus  can  be  found, 
usually  in  small  numbers,  in  the  giant  cells,  or  in  the  epithelioid  cells, 
or  between  them.  The  process  extends  by  the  formation  of  other  tu- 
bercles, apparently  due 
to  the  multiplication  of 
the  tubercle  bacilli  and 
their  diffusion  through 
the  tissues.  New  ne- 
crotic areas  like  the 
first  are  found,  which 
coalesce  and  form  a 
mass  of  caseous  mater- 
ial. Around  the  tuber- 
culous area  there 
appears  a  zone  of  non- 
tuberculous  granulation 
tissue  early  in  the  proc- 
ess. During  the  later 
and  reparative  stages  of 
the  process  this  area 
becomes  less  vascular 
and  is  converted  into 
denser  fibrous  tissue. 

As  the  individual 
tubercles  meet  and  co- 
alesce, they  form,  in  the 
marrow  of  the  bone,  ir- 
resfular  caseous  masses. 


i^S^ 


MOd' 


•".   ■^^1 


^Jv^v^v_wQ ,,;#-      y,         in  tnis  way  large  areas 
*^'   )' ■•;'^* '■^i*=**€'*'-        of  bone  may  be  involved 

by  peripheral   enlarge- 


ment  of  the  tuberculous 
area.     This   area    may 
soften   and  a  tubercu- 
lous bone  abscess  may 
result,  the  purulent  ma- 
terial  containing  bone 
fragments  like  sand. 
Instead  of  forming  a  "  bone  abscess  "  the  process  may  result  in  the 
formation  of  a  sequestrum  composed  of  necrotic  trabeculae  retaining 
their  shape  and  lying  in  a  cavity  in  the  bone.     x-\bout  the  sequestrum 
is  a  layer  of  granulation  tissue.     The  sequestrum  may  take  the  shape 


Fig, 


-Section  of  Tuberculous  Synovial  Membrane. 
(Nichols.) 


TUBERCULOUS  DISEASE   OF    THE  JOINTS. 


of  a  wedge  having  its  base  toward  the  joint,  in  which  case  it  is  known 
as  a  "  bone  infarct." 

As  the  diseased  focus  grows  larger  it  looks  more  yellow  in  spots, 
and  shows  at  its  centre  a  tendenc)-  to  cheesy 
degeneration,  and  later  in  the  history  of  the 
affection  one  finds  nodules,  varying  in  size 
from  that  of  a  pea  to  a  hazelnut,  which  are 
filled  with  a  putty-like  substance,  such  as  the 
cheesy  material  found  elsewhere  in  the  body, 
except  that  it  contains  spicules  of  bone  from 
the  trabeculae,  and  in  the  larger  foci  pieces  of 
dead  bone  of  considerable  size  are  found. 

Later  in  the  history  of  the  affection  the 
tuberculous  nodule  may  break  down  into 
purulent  material. 

Generally  the  original  focus  is  sur- 
rounded by  smaller  tubercles,  which  aid  in 
its  extension ;  but  the  chief  work  is  done 
by  the  erosive  action  of  the  granulations, 
which  take  the  place  of  the  progressively 
rarefied  bone. 

From  the  stage  of  tuberculous  infiltration  the  process  may  follow 
any  one  of  three  courses :  the  diseased  focus  may  be  absorbed  and  so 


Fig.  2.— Tumor  Albus.  Small  focus 
in  upper  epiphyseal  line  of  tibia. 
Synovitis  of  joint,  but  no  tuber- 
culous process  apart  from  focus- 
as  noted.  Death  from  miliary  tu- 
berculosis, a.  Epiphysis;  b,  pri- 
mary focus;  c,  shaft.     (Nichols.)- 


Fig.  3. -Tuberculous  Epiphysis.  Vertical  section  through  the  head  of  the  radius,  a.  Shaft  of 
radius;  b,  epiphyseal  cartilage;  c,  epiphysis;  d,  joint  surface;  cartilage;  <",  tuberculous 
primary  focus;  /",  perforation  of  joint  cartilage  and  infection  of  joint;  £',  tuberculous 
'■  pannus  "  extending  over  joint  cartilage.     (Nichols.) 


cured ;  it  may  extend  to  the  periphery  of  the  bone  and  break  through 
the  periosteum  and  empty  itself  there ;  or,  lastly  and  probably  most 
commonly,  it  may  extend  to  the  joint  and  infect  that. 


OR  TH  OPEDIC  S  UR  GER  V. 


1 .  The  absorption  of  the  diseased  focus  is  theoretically  possible  up 
to  a  late  stage  in  the  process,  so  long  as  the  disease  remains  strictly 
local  and  no  sequestra  of  an}-  size  have  formed ;  the  pus  ma}'  become 
cheesy  and  calcified. 

2.  The  next  most  favorable  termination  to  the  disease  is  when  the 
focus  does  not  infect  the  joint,  but  breaks  through  the  periosteum  and 
discharges  into  the  periarticular  structure.     This  happens  when  the 

focus  is  so  situated  that 
the  line  of  least  resist- 
ance takes  it  to  another 
part  of  the  bony  surface 
away  from  the  joint, 
there  forming  probabl}' 
an  abscess  which  must 
be  evacuated  externally 
or  break.  Sometimes 
this  ends  the  disease; 
the  granulation  tissue  be- 
comes fibrous,  and  then 
osseous,  and  the  disease 
is  over.  This,  according 
to  Krause,  is  most  likely 
when  the  focus  is  in  the 
upper  or  lower  end  of  the 
tibia  or  in  the  olecranon.' 
It  is  not  likely  to  occur 
in  the  hip  on  account  of 
the  extensive  distribu- 
tion of  the  capsule. 

3.  Probably  the  com- 
monest course  for  this 
localized  ostitis  to  pursue 
is  to  break  into  the  joint 
cavity,  and  the  ease  with 
which  infection  of  the 
joint  from  the  epiphysis 
is  produced  will  be 
readily  understood  b}'  considering  the  pathological  conditions. 

The  seat  of  the  disease  in  the  beginning  is  ordinarily  not  far  from 
the  cartilage.  At  first  it  excites  no  joint  inflammation,  but  when  it 
reaches  a  certain  stage,  even  before  it  breaks  into  the  joint,  inflamma- 
tory reaction  in  the  joint  begins."     The  inflammation  of  the  joint  at 

'  Krause  :  "  Tub.  der  K.  und  Gelenke."  1S91. 
-  Lannelongue  :  "  Co.xo-tuberculose."  Paris.  1S86. 


Pig.  4.  —  Section  of  Tuberculous  Synovial  Membrane. 
Numerous  tubercles  with  giant  cells.  Between  these, 
oedematous  granulation  tissue  with  many  lymphoid 
and  plasma  cells.     (Nichois.) 


TUBERCULOUS  DISEASE   OF   THE  JOINTS.  5 

first  is  non-tuberculous,  the  synovial  membrane  appearing  thick  and 
cedematous,  the  cavity  of  the  joint  being  filled  with  a  serous  inflamma- 
tory exudate.     This  process  may  be  very  extensive. 

Perforation  of  the  joint  by  the  tuberculous  focus  is  the  next  step  in 
the  process.  When  the  tuberculous  focus  underlies  it,  the  cartilage  of 
the  joint  begins  to  disintegrate  and  appears  softened  and  yellow,  and 


•i   * 


Fit;.  5.— Tuberculous  Knee,  Process  of    Repair   Advanced.     Small    focus  persists,     i?,  Tibia  ; 
/',  tuberculous  softening  ;  r,  femur  ;  d,  patella.     (Nichols.) 


finally  breaks  through.  The  perforation  frequentl)-  occurs  near  liga- 
ments. The  tubercle  bacilli,  having  entered  the  joint,  are  quickly  dis- 
seminated by  movement  of  the  articulation,  and  the  synovial  membrane 
becomes  infected. 

The  synovial  membrane  then  appears  thick,  smooth,  and  shining, 
and  sometimes  nodular;  the  surface  is  studded  with  small  .specks  not 
larger  than  the  head  of  a  pin.  The  yellow  tuberculous  areas  increase 
and  soften,  and  tuberculous  ulcers  of  the  synovial  membrane  form. 
The  thickened  synovial  membrane  extends  as  a  pannus  growth  over  the 


6  ORTHOPEDIC  SURGERY. 

edge  of  the  articular  cartilage,  sometimes  covering  the  whole  cartilage. 
At  the  same  time  the  tuberculous  process  may  extend  between  the  car- 
tilage and  bone.  The  cartilage  beneath  the  pannus  layer  is  destroyed 
and  disintegrated,  while  the  free  surface  of  the  cartilage  becomes  fibril- 
lated  and  ulcers  appear  in  it  also.  When  the  tuberculous  process  ex- 
tends beneath  the  cartilage  the  latter  is  eroded  and  destroyed. 

Large  areas  of  cartilage  may  be  detached  from  the  underlying  bone, 
and  sometimes  the  entire  cartilage  may  be  loosened,  as  in  the  hip-joint. 
Under  these  conditions  the  denuded  end  of  the  bone  is  seen  to  be  co\- 
ered  with  nodular  granulation  tissue  filled  with  tubercles,  caseous  and 
otherwise.  As  the  disease  goes  on  the  cartilage  is  destroyed  or  cast  off 
in  flakes,  and  the  denuded  bones  are  attacked  by  the  tuberculous  proc- 
ess and  are  eroded.  As  a  result  of  this,  articular  cavities  are  enlarged 
and  distorted,  and  distortions  and  subluxations  may  occur.  The  tonic 
muscular  contraction  accompanying  joint  disease  tends  in  certain  joints 
to  crowd  together  the  softened  ends  of  the  bones  and  hasten  the  wear- 
ing away. 

Microscopical  examination  of  the  diseased  area  at  any  time  before 
all  structure  is  lost  shows  a  typical  granulating  tuberculosis. 

Thickening  of  the  capsule,  infiltration  of  the  periarticular  tissues, 
and  thickening  of  the  ends  of  the  bones  are  clinical  manifestations,  and 
abscess  formation  and  all  the  other  complications  are  ready  to  follow. 

About  the  affected  joint  is  formed  a  layer  of  granulation  tissue 
which  may  be  converted  into  fibrous  tissue.  This  process  may  be  very 
extensive  and  accounts  for  such  phenomena  as  the  ovoid  swelling  in  tu- 
mor albus  and  the  thickening  of  the  trochanter  in  hip  disease.  This 
fibrous  tissue  may  be  oedematous,  and  the  spaces  may  contain  a  fluid 
reacting  to  stains  like  mucin. 

Repair  is  brought  about  by  the  formation  of  fibrous  tissue,  probably 
arising  from  the  layer  of  non-tuberculous  granulation  tissue  which 
grows  into  and  replaces  the  tuberculous  material.  Caseous  material  is 
largely  absorbed,  and  the  inspissated  remainder  is  replaced  by  fibrous 
tissue  or  is  calcified  and  encapsulated.  Fibrous,  cartilaginous,  or  bony 
ankylosis  may  result  from  the  process  of  repair. 

It  is  most  important  to  note  that  the  process  of  repair  may  be  in- 
complete, and  that  small  areas  of  tuberculous  material  encapsulated  by 
fibrous  tissue  may  persist  for  a  long  time  and  under  favorable  condi- 
tions may  become  active  and  cause  a  recurrence  of  the  disease.  This 
fact  must  alwa}-s  be  borne  in  mind  in  forcibly  manipulating  convales- 
cent tuberculous  joints.  Or  the  repair  may  be  complete  and  the  previ- 
ously inflamed  tissue  be  converted  into  cicatricial  bone — usually  more 
firm  than  the  original  structure. 

Certain  variations  of  this  process  must  be  described  as  other  t3'pes 
of  synovial  affection  from  that  described  are  found  at  times. 


TUBERCULOUS  DISEASE   OF   THE  JOINTS. 


7 


Arborescent  tuberculous  synointis  is  the  name  given  to  a  condition 
in  which  the  synovial  membrane  is  covered  with  branching  arborescent 
tags  frequently  coated  with  fibrin.  Sometimes  a  large  amount  of  fatty 
tissue  may  be  present,  constituting  the  "  lipoma  arborescens." 

•  Solitary  tuberculous  nodules  of  the  synovial  membrane  are  described. 
Nodular  and  even  polypoid  growths  with  little  tendency  to  caseation 


Fig.  6.— True  Ankylosis  of  the  Hip  Joint.     CJoachimsthal.) 


project  into  the  joint.  Although  at  first  the  rest  of  the  synovial  mem- 
brane is  but  little  affected,  it  becomes  involved  later. 

Hydrops  articiilonmi  tuberculosus  was  a  name  given  by  Konig  to  a 
chronic  effusion  of  joints  said  to  be  primarily  synovial.  In  these  there 
is  said  to  be  at  first  no  marked  thickening  of  the  synovial  membrane. 
Later  the  membrane  assumes  the  typical  character  of  tuberculous  syn- 
ovial inflammation.  A  similar  condition  of  joints  with  a  purulent  effu- 
sion is  described  as  "empyema  tuberculosum." 

It  has  always  been  asserted  by  writers  on  bone  tuberculosis  that 
primary  disease  of  the  synovial  membrane  occurred.     Volkmann,  how- 


8  ORTHOPEDIC  SURGERY. 

ever,  as  early  as  the  writing  of  his  classical  monograph,  said :  "  The 
fungous  inflammations  of  the  joints  begin  generally,  and  in  children 
almost  without  exception,  not  at  all  as  an  arthropathy,  but  as  a  pure 
osteopathy,  with  a  very  circumscribed  caseous  or  tuberculous  ostitis."  ' 

Nichols,-  in  one  hundred  and  twenty  tuberculous  joints  examined 
from  children  and  adults,  man}-  from  excisions,  a  considerable  number 
from  autopsies  or  amputations,  did  not  see  a  joint  in  which,  if  all  the 
bones  entering  into  the  joint  were  sawed  open,  one  or  more  old  bone 
foci  were  not  found.  Complete  examination  of  a  joint  at  operation  is 
usually  difficult  and  oftenest  impossible,  so  that  conclusions  as  to  the 
absence  of  primar}-  bone  disease  based  upon  such  examinations  must 
be  accepted  with  caution. 

Although  primar}'  tuberculosis  of  the  synovial  membrane  is  de- 
scribed by  those  whose  statements  carr)-  great  weight,  the  results  of 
Nichols'  investigations  must  be  borne  in  mind,  which  are  positive  and 
not  negative  conclusions.  And  it  may  be  assumed  for  clinical  purposes, 
until  the  contrar}-  is  proved,  that  practically  all  tuberculous  joint  dis- 
ease has  its  origin  in  bone. 

Cold  Abscesses  of  Joints. — If  the  tuberculous  process  in  the  bone 
reaches  the  surrounding  tissues  by  perforation  of  the  cortex  and  peri- 
osteum or  by  rupture  of  the  joint  capsule,  an  abscess  is  likely  to  occur. 
The  area  of  tuberculous  softening  in  the  periarticular  tissues  is  formed 
by  the  coalescence  and  caseation  of  tubercles.  Sun-ounding  the  soft- 
ened area  is  a  la3-er  of  tuberculous  tissue,  about  which  is  another  layer 
of  oedematous  and  vascular  granulation  tissue.  This  process  may  ex- 
tend until  a  large  cavity  has  been  formed. 

The  contents  of  these  abscesses  are  composed  of  caseous  material 
from  the  degeneration  of  the  tubercles  and  exuded  serum  with  necrotic 
pieces  of  bone.  In  the  fluid  are  poh^morphonuclear  leucoc3"tes,  often 
taking  up  little  or  no  stain  on  cover  slips.  Pyogenic  organisms  are  ab- 
sent unless  present  by  secondar\^  infection.  The  fluid  ma)' be  like  true 
pus ;  it  may  be  so  thick  that  it  will  hardly  flow ;  it  may  be  thin  and 
water}'  and  contain  coagula,  or  it  mav  be  red  or  brownish  from  hemor- 
rhage. 

Microscopically  tubercle  bacilli  may  be  found  in  the  abscess,  but 
they  are  to  be  identified,  even  after  prolonged  search,  in  onh-  about 
.one-third  of  the  cases.  In  such  cases  inoculation  experiments  must  be 
relied  upon  to  establish  their  presence. 

The  wall  of  these  abscess  cavities  is  composed  of  an  inner  layer  of 
tuberculous  tissue,  outside  of  which  is  a  layer  of  secondaiy  inflamma- 
tory" tissue.  The  inner  laver  may  be  granular  or  necrotic  and  ulcerated. 
The  abscess  extends  by  peripheral  enlargement  m  the  line  of  least  re- 

'  Volkmann  :  Klin.  Vortr..  v..  p.  1405. 
-Nichols:  Orth.  Trans.,  vol.  xi..  p.  3S3. 


TUBERCULOUS  DISEASE  OF   THE  JOINTS.  9 

sistance.  The  walls  of  tuberculous  sinuses  consist  of  an  inner  layer  of 
tuberculous  tissue,  outside  of  which  is  a  zone  of  oedematous  granulation 
tissue. 

Tubercle  bacilli  in  the  tissues  are  frequently  found,  though  not  in- 
variably, as  in  the  process  of  decalcification  necessar)' to  cut  sections  of 
bone  for  microscopic  examination  tlic\-  ma\-  become  so  disorganized  as 
to  stain  with  difficulty  or  not  to  stain  at  all. 

Inoculation  of  animals  with  tissue  from  bones  and  joints  affected  by 
this  type  of  disease  produces  general  tuberculosis,'  and  the  disease  may 
be  experimentally  produced  in  animals.' 

General  viilieiry  iiiberculosis  of  bone  occurs  in  connection  with  gen- 
eral miliary  tuberculosis.  The  marrow  is  studded  with  miliary  tuber- 
cles; necrosis  and  inflammatory  reaction  are  slight  or  are  absent.^ 

ETIOLOGY. 

Heredity. — That  heredity  is  a  factor  in  causing  tuberculous  joint 
disease  has  long  been  claimed.  Whether  the  tuberculous  virus  can  be 
directly  transmitted  as  such  from  father  or  mother  to  the  offspring 
must  still  be  held  open  to  question,'  but  that  the  surroundings  of  cer- 
tain families  weaken  the  resistance  and  favor  tuberculous  invasion  ap- 
pears not  improbable. 

Figures  which  attempt  to  show  what  proportion  of  children  with 
joint  disease  inherit  a  tendenc}"  to  these  diseases  are  notoriously  un- 
trustworthy. In  the  class  of  hospital  patients  from  whom  most  of 
these  statistics  come,  anything  approaching  accurate  information  with 
regard  to  the  diseases  of  which  relatives  have  died  cannot  be  expected. 
There  is  also  an  inclination  on  the  part  of  parents  to  deny  the  existence 
of  tuberculous  disease  in  their  parents  and  relatives.  In  this  wa-\-  pa- 
rents of  all  classes  are  much  more  anxious  to  establish  some  traumatic 
cause  for  the  affection  of  the  joint  than  to  have  it  supposed  that  the 
child  inherited  any  constitutional  taint.  Again,  it  must  be  remembered 
that  in  a  community  in  which  approximately  ten  per  cent  of  all  deaths 
are  from  phthisis,  phthisis  must  necessarily  appear  in  the  family  histo- 
ries of  a  certain  proportion  of  any  group  of  individuals  whose  antece- 
dents are  inquired  into.     For  these  reasons  the  statistics  cannot  be 

'- Cheyne  :  British  Med.  Jour..  April.  1891. 

-Deutsch.  Zeit.  f.  Ch..  1S72.  xi..  317.— Schiiller :  "Exp.  unci  histol.  Unter- 
suchungen,"  Stuttgart,  iSSo. — Cent.  f.  Ch..  1SS6.  Xo.  14. 

^  Konig :  Archiv  f.  klin.  Chir..  26.  p.  822. — Caumont :  Deutsch.  Zeit.  f.  Chir., 
XX.,  137. — Krause  :  Deutsch.  Chir..  Lief.  28a. — Deutsch.  med.  Woch..  18S6.  9-13.— 
Cent.  f.  Chir..  1887.  p.  52.— Quoted  by  Barber:  Brit.  r\Ied.  Jour.,  June  23d.  18S8.— 
Pfeiffer:  Fort,  der  Med..  1888.  Xo.  i.  p.  33.— For  further  detail  the  reader  is  re- 
ferred to  the  article  of  Nichols  (Trans-  Am.  Orth.  Assn.,  vol.  xi.),  which  has  been 
freely  used  by  the  writers. 

■*  Cheyne  :  "  Tuberculous  Disease  of  Joints."  p.  97. 


10  ORTHOPEDIC  SURGERY. 

regarded  as  other  than  inaccurate,  and  only  approximating  the  truth, 
but  the  error  is  hkely  to  lie  always  on  one  side,  in  making  the  propor- 
tion of  inheritance  too  small.' 

Traumatism. — Experimentally  it  has  been  shown  that  trauma  to  the 
joint  of  a  tuberculous  animal  may  cause  tuberculous  joint  disease,  but 
that  it  does  not  do  so  in  the  healthy  animal.  It  has  been  established 
that  contusions  and  wrenches  cause  the  effusion  of  blood  in  the  spong}^ 
tissue  of  the  bone.  Cases  are  seen  in  which  tubercles  develop  directly 
from  the  clot,  just  as  in  a  syphilitic  individual  a  gumma  may  develop 
at  the  site  of  an  injury  to  the  bone.  "There  are  cases  in  which  the 
swelling  from  the  fall  merges  into  the  tuberculous  swelling."  -  It  would 
therefore  seem  rational  to  assume  that  trauma  caused  tuberculous  joint 
disease  in  children  who  inherited  a  constitutional  taint.  But  it  becomes 
evident  at  once  that  this  is  not  all,  for  every  surgeon  of  experience 
must  have  in  his  mind  cases  in  which  joint  disease  of  a  tuberculous 
type  has  followed  injur}"  in  children  whose  family  histories  were  excep- 
tionally good. 

From  one-sixth  to  one-half  of  all  cases  would  appear  from  the  col- 
lected statistics  to  be  traumatic. 

In  certain  cases  traumatism  alone  must  be  accepted  as  the  causative 
factor,  while  in  some  cases  no  cause  can  be  assigned. 

The  cxantJicniata  must  be  mentioned  as  being  the  cause  of  tubercu- 
lous joint  disease  in  a  certain  proportion  of  cases,  probably  a  larger 
proportion  than  has  been  suspected.  Measles  and  scarlet  fever  are  the 
most  common  eruptive  diseases  to  be  followed  by  these  sequelae. 
There  are  very  few  figures  bearing  upon  the  subject.  The  effect  of 
the  exanthemata  in  causing  other  forms  of  joint  disease  will  be  alluded 
to  later. 

The  entrance  of  the  bacilli  is  apparently  most  often  through  the 
respiratory  and  digestive  tracts. 

It  is  probable  that  whatever  continuously  diminishes  the  power  of 
resistance  and  of  repair  in  growing  children  increases  what  may  be 
termed  the  vulnerability  of  the  epiphyses,  and  furnishes  the  soil  for  the 
development  of  tubercle  bacilli  and  the  consequent  results. 

Age. — Tuberculous  joint  disease  is  pre-eminently  a  disease  of  child- 
hood. It  is  not  congenital,  and  under  one  year  it  is  not  common. 
The  majority  of  cases  occur  between  three  and  ten  years  of  age." 

'  Gibney  :  "  Strumous  Element  in  Joint  Disease."  N.  Y.  Med.  Jour..  Jul}-,  1877. 
— From  preface  of  German  translation  of  " '  le  Mechanical  Treatment  of  Pott's 
Disease." — Croft:  Clin.  Soc.  Transactior  London,  vol.  xiii. — Nichols:  Orth. 
Trans.,  xi.,  p.  358. 

-Konig:  Deutsch.  Zeit.  fiir  Chir.,  1S79   ^i. 

"X.  M.  Shaffer:  "Am.  Clin.  Lectures,"  vol.  iii..  141:  Sonnenberg:  Arch,  f, 
klin.  Chir..  iSSi,  xxvi.,789:  Lannelongue :  Loc.  cit. — "Hip  Disease  in  Child- 
hood." p.  2. — L.  A.  Sayre  :  "  Orthopedic  Surgery  and  Diseases  of  Joints." 


TUBERCULOUS  DISEASE   OF    THE  JOINTS.  II 

The  liability  of  the  aged  to  tuberculous  joint  disease  must  not  be 
overlooked.'  The  patients  may  be  seventy-five  or  ninety,  and  cases  of 
hip  disease  present  the  same  pathological  appearances  here  as  in 
young  children.  The  course  of  the  disease  is  more  rapid  and  destruc- 
tive than  in  the  young,  and  its  etiological  relations  are  decidedly  more 
obscure. 

The  reasons  why  tuberculous  joint  disease  affects  children  to  so 
great  an  extent  are  as  follows : 

In  the  active  period  of  growth  more  change  is  going  on  and  there- 
fore more  instability  exists  and  consequently  greater  liability  to  disease. 
Children  are  more  liable  to  falls  and  injuries,  which  are  such  a  fertile 
source  of  joint  and  bone  lesions.  It  is  not  till  after  puberty  that  the 
process  of  natural  selection  has  eliminated  the  weaklings  from  the 
stock.  Children  are  kept  quiet  less  easily  than  adults,  and  a  slight  in- 
jury ma)"  develop  into  a  formidable  disease.  Tuberculosis  in  general 
is  common  in  childhood. 

Sex  is  not  a  factor  of  any  prominence,  but  there  is  a  slightly  larger 
proportion  of  tuberculous  joint  disease  among  boys  than  among  girls."^ 

Distribution  of  Chronic  Tuberculous  Joint  Disease. — The  relative 
frequency  with  which  tuberculosis  attacks  the  various  joints  in  children 
may  be  estimated  from  the  following  figures: 

At  the  Children's  Hospital,  from  1869  to  1903  inclusive,  5,950  cases 
of  tuberculosis  of  the  joints  were  distributed  as  follows:  spine,  2,867; 
hip,  2,281;  knee,  375;  ankle,  394;  elbow,  33.  These  practically  all 
occurred  in  children  under  the  age  of  twelve. 

In  211  cases  of  joint  tuberculosis  among  the  out-patients  occurring 
in  children  under  two  years,  there  were  120  cases  of  Pott's  disease,  61 
of  hip  disease,  and  29  of  tuberculosis  of  the  knee-joint." 

Judson  has  called  attention  to  the  great  preponderance  of  joint  dis- 
ease in  the  lower  extremity  as  contrasted  with  the  upper  limb.  Ana- 
lyzing the  reports  of  two  orthopedic  institutions  in  New  York  City,  he 
found  that  in  a  single  year  the  following  number  of  cases  of  disease  of 
the  different  joints  were  treated: 

Hip-joint  di.sease 577 

Knee-joint  disease iSi 

Shoulder  disease 6 

Elbow  disease S 

or  758  patients  had  disease  of  the  joints  of  the  lower  extremity,  while 
in  the  same  time  there  appeai  ^  only  14  cases  of  joint  disease  in  the 
upper  extremity. 

In  joint  disease,  when  one     r  more  articulations  are  involved,  any 

'  "  Clinical  Lectures  and  Essays.     Senile  Scrofula."  2d  ed..  p.  345. 
-Gibney:  Loc.  cit..  p.  206. 
^Thomdike:  Orth.  Trans.,  ix.,  p.  196. 


12  ORTHOPEDIC  SURGERY. 

combination  may  be  found ;  but  the  most  common  are  hij)  disease  and 
Pott's  disease,  knee  disease  and  Pott's  disease,  and  double  hip  disease. 
Disease  of  the  knee-  and  hip-joint  at  the  same  time  is  not  common,  and 
double  tumor  albus  is  unusual. 

DIAGNOSIS. 

The  recognition  of  tuberculous  joint  disease  is  to  be  based  upon  cer- 
tain general  phenomena  modified  by  the  anatomical  conditions  of  the 
joint  affected.  These  diagnostic  signs  are  considered  in  connection 
with  the  individual  joints. 

The  use  of  tuberculin  as  a  means  of  diagnosis  is  open  to  the  criti- 
cism that  its  results  are  attended  with  so  much  uncertainty  that  its 
value  in  the  individual  case  is  always  open  to  question  and  cannot  be 
assumed  to  be  a  reliable  demonstration  that  tuberculosis  is  either  pres- 
ent or  absent  in  that  case.'  It  has  been  demonstrated  that  in  a  certain 
per  cent  of  well-marked  cases  of  pulmonary  or  other  tuberculosis,  tu- 
berculin gives  a  negative  result,  while  in  other  cases,  presumably  non- 
tuberculous,  a  certain  percentage  of  positive  results  is  obtained.  The 
great  frequency  of  tuberculous  invasion  has  been  shown  by  the  autop- 
sies of  Babes,"  for  example,  who  found  lesions  of  the  bronchial  glands 
in  more  than  one-half  of  his  autopsies  on  children ;  and  those  of  Nae- 
geli,^  who  found,  in  508  consecutive  autopsies,  that  97  to  98  per  cent 
showed  evidences  of  tuberculosis.  Under  these  circumstances  tuber- 
culin must  necessarily  be  unreliable  in  demonstrating  joint  tubercu- 
losis.^ 

The  inoculation  of  material  from  suspected  joints  into  guinea-pigs 
forms  a  reliable  means  in  the  diagnosis  of  tuberculosis  of  the  joints. 

The  x-ray  is  an  aid  in  the  diagnosis  of  joint  tuberculosis  where  the 
process  is  sufficiently  advanced  to  have  caused  the  absorption  of  lime 
salts  in  the  affected  area  or  to  have  destroyed  any  part  of  the  bony 
structure.  In  early  cases  the  radiograph  may  be  normal  when  disease 
is  present. 

PROGNOSIS. 

The  destructive  process  which  is  so  prominent  a  feature  of  joint 
tuberculosis  is  almost  from  the  first  accompanied  by  a  reparative  proc- 
ess tending  to  limit  the  destruction,  protect  the  surrounding  tissues, 
and  prevent  generalization.     The  prognosis  depends  in  the  individual 

'  F.  \V.  White:  Boston  ^led.  and  Surg.  Journal.  August  5th.  189S  (with  bibH- 
ography). — Schliiter:  Deutsch.  med.Woch.,  1904.  viii..3o.  p.  272  (with  literature). 
Brit.  Med.  Journ.,  1903,  vol.  ii.,  pp.  48,  96. 

'■'Babes,  quoted  by  Burrell :  "Surg.  Tub.."  Trans.  Mass.  Med.  Soc  ,xix.,  1903. 

•'Naegeli :  Arch,  fiir  path.  Anat.,  vol.  clx. 

•*"  Indirect  Tuberculin  Reaction."  Bull,  de  ITnstitut  Pasteur,  t.  ii.,  April  30, 
1904.  p.  III. 


TUBERCULOUS  DISEASE   OF   THE  JOINTS.  13 

case  upon  which  of  these  two  processes  prevails  over  the  other.  The 
former  is  favored  by  inel^cient  local  treatment,  bad  inheritance,  poor 
general  condition,  unfavorable  surroundings,  and,  in  general,  what  may 
be  termed  poor  resistance  to  the  tuberculous  process.  The  reparative 
process  is  favored  by  the  reverse  of  these  conditions,  in  the  majority 
of  all  cases  of  joint  tuberculosis,  properly  treated  at  a  fairly  early  stage, 
the  outlook  is  favorable.  The  prognosis  is  more  favorable  in  children 
than  in  adults. 

TREATMENT. 

Since  bone  tuberculosis  has  been  shown  to  be  one  manifestation  of 
tuberculous  infection  and  not  the  result  of  an  unknown  evil,  the  prin- 
ciples of  treatment  are  more  clear. 

Resistance  to  the  infection  by  the  tubercle  bacillus  is  furnished 
when  the  individual  is  in  a  normal  state.  The  antidotes  to  be  relied 
upon  to  check  its  advance  after  it  has  found  lodgment  are  not  only  good 
air  and  food,  but  such  general  activity  as  will  promote  normal  metabol- 
ism. Tuberculosis  is  prevalent  and  fatal  among  caged  animals — a  fact 
Avhich  is  to  be  borne  in  mind  in  the  treatment  of  bone  tuberculosis. 

The  treatment  is  both  general  and  local.  The  general  treatment 
consists  in  giving  the  patient  the  best  possible  environment  and  in  fur- 
nishing such  conditions  that  normal  activity  will  cause  the  least  possi- 
ble, injury  to  the  part  locally  affected. 

In  tuberculosis  of  the  lung  the  patient  is  in  constant  danger  of  self- 
infection  or  increase  of  the  process  from  the  inhalation  of  infected 
material.  In  bone  tuberculosis  no  such  danger  exists.  Strong,  well 
ossified  bone  does  not  offer  suitable  soil  for  the  bacillus.  Bone  tissues 
when  invaded  resist  the  advance  of  tuberculous  infection  by  surround- 
ing the  diseased  area  with  a  thick  enveloping  mass  of  tissue  and  by 
subsequently  repairing  the  invaded  region  by  the  development  of  strong 
bone.  Traumatism,  which  injures  this  bone  construction  and  furnishes 
unde\'eloped  cells  instead  of  firm  bony  structure,  favors  the  spread  of 
the  tuberculous  process. 

The  treatment  of  bone  tuberculosis,  therefore,  consists  in  promoting 
such  general  conditions  as  will  favor  repair  (general  treatment)  and  the 
protection  of  the  parts  from  injury  during  the  disease  (local  treatment). 

General  Treatment. — The  patient  should  be  placed  in  the  most  fa- 
vorable environment  available  in  the  matter  of  food,  home  surround- 
ings, air,  sunlight,  proper  clothing,  exercise,  avoidance  of  fatigue,  and 
similar  requirements. 

Outdoor  Treatment. — Of  these  requirements  outdoor  air  is  of 
the  utmost  importance,  and  the  open-air  treatment  of  surgical  tubercu- 
losis '  is  nowhere  more  beneficial  than  in  joint  disease.     The  outdoor 

'Burrell:  Comm.  Mass.  Med.  Soc,  1903,  xix.,  11,  p.  303. 


14  ORTHOPEDIC  SURGERY. 

method  recognized  as  of  such  value '  in  the  treatment  of  pulmonary 
tuberculosis  is  advisable.-'  During  the  day  the  patient  should  be  out 
of  doors  or  in  a  room  with  one  or  more  windows  open.  In  winter 
proper  protection  against  cold  should  be  obtained  by  warm  clothes 
rather  than  by  heated  rooms.  Such  patients  should  sleep  out  of  doors 
in  tents  or  well-aired  sheds.  During  the  summer  this  offers  little  diffi- 
culty, and  in  the  winter  such  treatment  is  available  even  in  a  New 
England  climate.  From  Christmas,  1903,  through  the  winter,  the  pa- 
tients at  the  Convalescent  Home  of  the  Children's  Hospital  at  Welles- 
ley,  with  Pott's  disease  and  hip  disease,  lived  and  slept  in  an  unheated 
shed  with  skylights  or  doors  open.  Properly  protected  by  woollen  caps 
and  heavy  blankets,  they  suffered  no  discomfort,  and  the  beneficial 
effect  on  the  local  process  was  evident. 

The  importance  of  the  treatment  by  fresh  air  and  sunlight  has  been 
recognized  in  Europe  in  the  establishment  of  seaside  sanatoriums  for 
children  with  tuberculous  joint  disease.  It  is  being  recognized  in 
America  that  a  convalescent  home  in  the  country  is  an  almost  neces- 
sary part  of  a  surgical  hospital  for  children. 

Drugs. — The  writers  are  of  the  opinion  that  drugs,  except  tonics 
when  required,  are  of  little  or  no  value  in  the  treatment  of  joint  tuber- 
culosis. 

Local  Treatment. — Fixation,  distraction,  and  protection,  along  with 
operative  treatment,  are  considered  in  speaking  of  the  individual  joints. 
Other  local  measures  are  occasionally  of  use,  in  addition. 

Biers  congestive  treatment  ^  depends  upon  hypersemia  as  a  thera- 
peutic agent,  and  in  connection  with  proper  mechanical  treatment  it 
may  be  of  benefit  in  the  knee,  ankle,  elbow,  or  wrist.  A  congestion 
of  the  affected  joint  is  induced  by  bandaging  above  and  below  the 
joint  with  cotton  webbing  or  rubber  bandages  and  allowing  the  con- 
gestion to  continue  for  an  hour  daily.  The  congested  parts  should  feel 
warmer  than  the  normal  skin,  but  the  process  should  never  be  pushed 
to  the  degree  of  causing  pain. 

X-ray  treatmeiit  consists  in  an  exposure  of  the  affected  joint  to  the 
x-rays  for  a  certain  period  every  day  or  every  second  day.  In  a  fairly 
large  number  of  cases  of  joint  tuberculosis  under  mechanical  treatment 
treated  in  this  way  in  addition,  checked  by  cases  under  similar  condi- 
tions not  so  treated,  the  writers  have  not  been  able  to  detect  any  bene- 
fit from  the  use  of  the  x-ray. 

Counter-in  itation,    inunction,   zgnipuncture,   and   similar    measures 

^  Aled.  Record,  November  iSth,  1902,  p.  736.  Am.  JNIed.,  March  21st,  1903, 
440.     Miinch.  med.  Woch.,  1902,  xlix.,  1081. 

-Zeitsch.  f.  Tub.  und  Heilstatt.,  July,  1902,  pp.  366  and  369. 

^  Frieberg  :  Am.  Journ.  Orth.  Surg.,  August,  1904.  ii..  150. — Luxembourg: 
Miinch.  med.  Woch.,  1904,  10. 


TUBERCULOUS  DISEASE   OF   THE  JOINTS.  15 

have  fallen  into  more  or  less  disuse  since  the  better  appreciation  of  the 
pathology  of  joint  tuberculosis  and  the  essentials  of  its  treatment. 

Massage,  manipulation,  hot-aii'  baths,  doncJics,  and  similar  measures 
to  stimulate  the  local  circulation  are  to  be  avoided  during  the  acute 
stage  of  the  process  as  essentially  undesirable.  In  late  convalescence 
they  may  prove  of  much  value. 


CHAPTER    II. 

TUBERCULOUS    DISEASE    OF    THE    SPINE. 

Definition.  —  Histon-.  —  Pathology.  —  Occurrence  and  Etiology.  —  Symptoms.  — 
Complications.  —  Diagnosis.  —  Differential  Diagnosis.  —  Prognosis. —  Treat- 
ment. 

Definition. — Pott's  disease  is  the  name  applied  to  a  destructive  path- 
ological process  which  attacks  the  bodies  of  the  vertebrae.  The  other 
names  by  which  the  affection  is  known  are  as  follows :  Spondylitis, 
Malum  Poitii,  Caries  of  the  spine,  Kyphosis,  Angular  curvature,  Tu- 
berculosis of  the  vertebrae,  and  Spinal  curv'ature.  In  German  it  is 
known  as  Die  Potfsche  Kyphose,  Spitzbnckel,  Winkelforinigc  Kiiicknng 
der  Wirbelsdule,  and  TnbcTcnlosc  Wirbclcntziindung ;  in  French  as 
CypJiose,  Mai  de  Pott,  and  Mai  Vertebral. 

History. — Antero-posterior  curvature  of  the  spine  is  an  affection 
which  was  described  by  the  ancients,  and  was  known  to  Hippocrates 
and  Galen,  who  attributed  its  cause  to  tubercle  '"  within  and  without  the 
lungs."'  Ambroise  Pare  wrote  of  it  and  used  a  metal  cuirass  in  its 
treatment,  but  it  was  not  until  the  time  of  Percival  Pott,  in  1779,  that 
any  accurate  description  of  the  disease  was  given.'  In  honor  of  that 
surgeon  the  disease  is  chiefly  known  by  his  name.  The  existence  of 
the  disease  in  prehistoric  times  in  North  America  is  proved  by  a  speci- 
men in  the  Peabody  Museum,  Cambridge,  Mass. 

PATHOLOGY. 

Pott's  disease  represents  the  result  of  a  destructive  ostitis  affecting 
the  spong}'  tissue  of  one  or  more  of  the  vertebral  bodies.  This  ostitis 
is  tuberculous  in  type  and  follows  the  same  course  as  tuberculous 
ostitis  occurring  at  the  epiphyses  of  the  long  bones,  as  in  hip  disease, 
tumor  albus,  etc. 

The  first  appearance  noticeable  to  the  naked  eye  on  examining  a 
■section  of  a  diseased  vertebra  at  an  early  stage  of  the  disease  is  a  small 
hyperaemic  spot  in  some  part  of  the  spongy  portion  of  the  body  of  the 
vertebra,  generally  near  the  anterior  surface  of  the  body.  This  spot 
grows  larger  and  more  red  as  the  process  extends,  and  finall}'  the  cen- 
tre becomes  opaque  and  grayish,  while  a  zone  of  hyperasmia  surrounds 

'Pott:  "Remarks  on  that  Kind  of  Palsy  Affecting  the  Lower  Limbs."  etc., 
London,  1779. 

16 


TUBERCULOUS  DISEASE   OF   THE  SPINE. 


17 


it.  A  focus  of  tuberculous  ostitis  is  present.  If  this  process  extends, 
the  opaque  spot  becomes  larger,  and  finally  cheesy  degeneration  of  its 
centre  takes  place.  At  other  times  both  caseation  and  degeneration 
into  tuberculous  pus  take  place,  and  a  localized  abscess  of  bone  exists, 
probably  encapsulated  in  a  membrane  of  inflammatory  tissue,  which  sur- 
rounds the  focus,  endeavoring  to  protect  the  surrounding  healthy  bone 


Fig.  7.— Pott's  Disease  Involving  the  whole  Dorsal  Region.     Prehistoric  Indian  remains. 
(Peabody  Muse^im,  Spec.  17,223.) 


from  the  erosive  action  of  the  focus.  Microscopical  examination  shows 
a  mass  of  tubercles  in  a  rarefied  spongy  bone  tissue,  and  in  the  tuber- 
cles are  to  be  found  tubercle  bacilli. 

The  focus  of  tuberculous  material  may  either  be  absorbed  or  calci- 
fied, or,  as  happens  much  more  commonly,  the  ostitis  may  increase 
until  it  has  destroyed  a  large  part  or  the  whole  of  a  vertebral  body.  In 
its  course  of  enlargement  it  may  include  portions  of  bone,  the  nutrition 
of  which  is  cut  off  by  the  adjacent  inflammatory  destruction.  Such 
portions  necessarily  become  necrosed,  and  with  caseous  matter,  granu- 
lation tissue,  and  the  products  of  inflammation  constitute  an  area  of 
altered  and  degenerated  structure  in  the  vertebral  body.  If  this  dis- 
eased area  has  become  large  enough,  the  vertebral  body  gradually  be- 
comes incapable  of  sustaining  as  much  pressure  as  before.     From  the 


i8 


ORTHOPEDIC  SURGERY. 


])eculiar  weight-bearing  function  of  the  vertebral  column,  the  pressure 
upon  each  vertebral  boch'  is  always  considerable  when  the  vertebral  col- 
umn is  in  the  erect  position.  If  one  vertebral  body  is  becoming  exca- 
\-ated,  a  point  will  be  reached  where  it  can  no  longer  sustain  the  weight, 
but  must  give  way  slowly  or  suddenly.  A  forward  tilt  of  the  whole 
vertebral  column  above  the  seat  of  disease  is  then  inevitable,  with  a 
certain  amount  of  backward  angular  deformit}-  at  the  diseased  vertebra. 
This  is  the  mechanism  of  the  production  of  the  knuckle  in  the  back. 


Fig.  8.  —  Lower  Dorsal  Region.  One 
intervertebral  disc  destroyed.  E.k- 
tension  of  process  backward  to  dura 
and  formed  along  prevertebral  liga- 
ments. Moderate  knuckle  hardened 
in  upright  position,  so  that  gravity 
pressed  diseased  vertebrae  together. 
a.  Tuberculous  softening-    (Nichols.) 


b-' 


Fig.  q.  —  Lower  Dorsal  Region.  Opposite  half  of 
specimen  rested  on  knuckle  while  hardening, 
so  that  gravity  extended  the  spine.  Marked 
separation  of  diseased  vertebrae,  a,  Tuberculous 
disease  beneath  prevertebral  ligaments;  b,  cav- 
ity between  diseased  vertebrae.     (Xichols.") 


It  is,  in  brief,  a  softening  and  crushing  of  one  or  more  vertebral  bodies 
and  a  giving  way  of  the  column  at  that  point  as  a  necessary  mechanical 
result. 

This  process  is  limited,  as  a  rule,  to  the  vertebral  bodies ;  the  trans- 
verse, articular,  or  spinous  processes  are  rarely  affected  secondarily  or 
primarih",  their  structure  of  hard  bone  apparently  protecting  them  from 
tuberculous  invasion. 

The  intervertebral  eartilage  between  the  diseased  vertebrae  becomes 
fibrillated  and  disintegrated  and  disappears. 

There  may  be  two  or  more  foci  in  one  \-ertebra,  or  the  whole  body 
may  be  equally  affected ;  the  disease  ma}"  be  limited  to  one  spot,  forming 


TUBERCULOUS  DISEASE   OF   THE  SPINE. 


19 


a  localized  abscess  of  the  bone,  or  it  may  extend  so  as  to  involve  the 
adjacent  \-ertebrcc.  If  the  disease  remains  limited  to  the  centre  of  the 
vertebra,  l^ut  little  deformity  ma}'  result.  Primary  disease  of  two  ver- 
tebral bodies  in  different,  non-adjacent  parts  of  the  spine  is  rare.  But 
an  extensive  destruction  of  two  or  more  adjacent  vertebrae  from  pri- 
mary disease  of  one  ma_\-  be  said  to  be  the  rule  in  Pott's  disease.  In 
some  instances  this  destructive  process  may  be  limited  to  the  surfaces 
of  a  large  number  of  vertebral  bodies;  in  others  a  few  contiguous  ver- 


FiG.  10. — Spine,  Lower  Dorsal  and  Lumbar  Region.  Extreme  knuckje.  Lower  ribs  rest  on 
pelvis.  Chang-e  in  angle  of  ribs  due  to  continued  deformity.  Calibre  of  spinal  canal  not 
diininished.     <?,  Knuckle.     (Nichols.) 

tebral  bodies  are  completely  destroyed.  The  number  of  vertebrae  in- 
volved necessarily  varies ;  in  some  instances  the  bodies  of  twelve  or 
even  more  have  been  destroyed,  producing  a  deformity  which  involves 
almost  the  whole  of  the  spinal  column.  A  superficial  ostitis  of  the  an- 
terior surfaces  of  the  bodies,  without  involving  the  intervertebral  carti- 
lages or  impairing  the  weight-bearing  function  of  the  vertebrae,  occurs, 
but  is  rare. 

Abscess. — "  In  a  considerable  portion  of  cases  of  tuberculous  disease 
of  the  spine  no  abscess  is  recognized  during  life,  but  in  cases  seen  at 
autopsy  an  abscess  is  almost  invariably  found,  although  it  may  be  of 
small  size.  The  tuberculous  material  early  pushes  up  the  prevertebral 
ligaments  and  forms  a  flattened,  soon  a  nodular  swelling  in  front  or 
sometimes  to  one  side  of  the  vertebrae.  The  contents  of  such  a  swell- 
ing are  like  the  contents  of  other  tuberculous  abscesses  "  (Nichols).' 

'  Nichols:  Orth.  Trans.,  vol.  xi..  p.  391. 


20 


ORTHOPEDIC  SURGERY. 


In  certain  cases  the  formation  of  tuberculous  pus  is  a  characteiistic 
of  the  disease  from  the  first,  and  in  these  cases  abscesses  are  apt  to  be 

a  conspicuous  feature.  The  tu- 
berculous pus  finds  its  way,  dur- 
ing or  after  the  destruction  of 
the  body  of  the  vertebra,  into  the 
surrounding  tissues  and  gravi- 
tates downward.  It  appears  usu- 
ally in  the  course  of  the  sheath 
of  the  psoas  muscle  when  the 
disease  is  situated  in  the  lower 
half  of  the  spine,  but  the  site  of 
the  abscess  necessarily  depends 
upon  the  place  of  the  original 
disease,  and  may  be  in  the  mouth 
— as  in  retropharyngeal  abscess 
— in  the  neck,  in  the  axilla,  or 
in  the  back,  lungs,  abdomen,  or 
groin.  The  contents  of  such  ab- 
scess as  a  rule  contain  no  pyo- 
genic bacteria. 

Paralysis. — In  certain  cases 
meningitis  and  myelitis  are  pres- 
ent in  the  cord  opposite  the  seat 
of  disease,  accompanied  some- 
times b}^  what  is  virtually  the 
destruction  of  the  cord  at  that 
point.  The  paralysis  is  very 
rarely  caused  by  direct  pressure 
of  bone,  as  it  is  uncommon  for 
even  very  marked  deformities  of 
the  spine  to  narrow  the  spinal 
canal  to  any  great  extent.  More- 
over, paralysis  sometimes  occurs 
before  there  is  any  deformitv, 
and  it  often  recovers  while  the 

Pig.   II.— Lower  Liimbar  Region.     Section   ob-  deformity      gCtS      WOrSC.         Many 

liquely  through  lumbar  vertebra,  and  ilium  in  ^^^^^  ^^^j^^  extreme  deformity  are 
the  Ime  of  the  ilio-psoas  muscle.    Small  tuber-  -' 

culous  area  in  lowest    lumbar  vertebra.    In  llCVCr    paralyzed     at    all.       In     52 

pelvis  is  large  tuberculous  abscess  in  sheath  of  ^^^^^  collected  f  rom  literature  bv 
iho-psoas    muscle,     a,  Tuberculous    focus    in 

lumbar  vertebrse;  5,  peritoneum  and  sheath  of  SchmaUS  ^    ill    wllicll    autOpsy    af- 

iiio-psoas:.,  abscess;  rf,  ilium.    (Nichols.)        {q^^^^  a  chancc  of  determining 
the  cause  of  the  paralysis,   compression   was  mentioned   as   a   cause 
'  Schmaus:  "  Die  Compression-Myelitis  der  Caries,"  etc.,  Wiesbaden,  1S90. 


TUBERCULOUS  DISEASE   OF   THE  SPINE. 


21 


in  only  39  cases;  in  33  of  these  a  caseous  pachymeningitis  was 
noted.  In  6  bony  pressure  existed,  and  in  5  of  these  the  odontoid 
process  of  the  axis  was  dislocated.  In  only  i  was  kyphotic  displace- 
ment the  cause  of  the  pressure.  Kraske '  estimates  bony  pressure 
as  the  cause  in  two  per  cent  of  the  cases.  Autopsy  shows  that  in 
cases  of  paralysis  the  process  ordinarily  begins  as  an  external  pachy- 
meningitis. Compression  from  thickened  meninges  must  therefore 
be  classed  as  one  cause  of  paralysis.  This  meningitis  is  generally 
dearly  tuberculous  in  character.     Myelitis  or,  better,  meningomyelitis, 


Fig. 


-Sagittal  Section  of  the  Spine  from  the  gth  Dorsal  to  the  2nd  Lumbar.     Compression 
of  cord  and  abscess.    (Schulthess.) 


however,  at  times  exists  from  an  early  stage  in  the  cord  itself.  This  is 
not  to  be  demonstrated  as  tuberculous  by  the  microscope.  This  menin- 
gomyelitis is  followed,  if  it  is  severe  enough,  by  ascending  and  de- 
scending degenerations  in  the  columns  of  the  cord.  CEdema  also  is 
present,  at  first  apparently  non-inflammatory  in  character,  but  later 
inflammatory.  This  also  must  be  a  factor  in  producing  symptoms,  and 
alone  explains  the  immediate  improvement  in  certain  cases  after  forci- 
ble rectification  of  the  deformity.  Thrombosis  and  embolism  of  spinal 
vessels  must  be  accounted  as  possible  factors  in  contributing  to  the 
'  Kraske  :  Archiv  f.  klin.  Chir..  vol.  Ixi. 


2  2  ORTHOPEDIC  SURGERY. 

disturbance  in  the  cord.  The  order  of  changes  is  as  follows:  oedema, 
diffuse  softening,  and  sclerosis.  If  the  myelitis  ceases,  it  leaves  a  cer- 
tain amount  of  sclerosis  of  the  cord  at  the  seat  of  the  disease.  This, 
again,  ma}-  be  very  slight,  or  the  cord  may  be  reduced  to  a  fraction  of 
its  former  size,  and  yet  ser\"e  well  enough  to  transmit  healthy  nervous 
impulses. 

There  ma"\"  be  a  direct  strangulation  of  the   cord   by  the  vertebral 
arches,  obliterating  the  canal ;  or  an  abscess  from  diseased  bone  mav  be 


h .. 


Fig.  13.— Tuberculosis  of  Lower  Dorsal 
Reg'ion.  Large  area  of  tuberculous  soft- 
ening involving  two  vertebrae.  Inter- 
vertebral disc  destroyed.  Process  ex- 
tends forward  beneath  prevertebral 
ligaments  and  pushes  aorta  forw^ard. 
Process  also  extends  backward  to  dura. 
a.  Beginning  abscess  ;  b,  aorta  :  c.  tuber- 
culous softening  of  vertebrae.  (Xicbols.) 


Fig.  14. — Lower  Dorsal  and  Upper 
Lumbar  Vertebrse.  Tuberculous 
softening  in  anterior  portion  of 
bodies  of  five  vertebrse.  Marked 
knuckle.  Portion  of  one  vertebra 
pushed  backward  into  spinal  ca- 
nal, but  does  not  produce  pressure 
upon  spinal  cord.  <?,  Tuberculous 
disease  of  vertebra  ;  b.  tubercu- 
lous foci ;  r,  cord  ;  </,  fragments  of 
bone  projecting  into  spinal  canal. 
(Nichols.) 


a  source  of  pressure  within  the  canal.  A  caseous  deposit  from  the 
vertebra;  and  a  loose  piece  of  bone  have  been  found  as  sources  of 
pressure. 

In  proportion  to  the  extent  of  the  disease  and  the  number  of  verte- 
brae involved,  an  angular  deformity  of  the  spine  may  be  present  to  any 
extent.  In  severe  cases  this  angular  deformity  leads  to  many  second- 
ary pathological  changes.  The  shape  and  capacity  of  the  chest  are 
necessarily  very  much  altered,  and  the  ribs  sometimes  sink  into  the 
pelvis.  As  a  result  of  these  changes  in  chest  capacity,  hypertrophy  of 
the  heart,  often  accompanied  by  valvular  disease,  is  common.  The 
aorta  may  be  distorted  as  a  result  of  the  deformit}-.  Thomas  D wight 
reports  a  case  in  which  its  course  "  might  be  compared  to  an  S  lying 
on  its  side,  with  the  ends  bent  strongly  back  to  fit  around  the  promi- 


TUBERCULOUS  DISEASE   OE   THE  SPINE. 


nence  of  the  spine."  '  Lannelongue  "  found  a  very  marked  narrowing 
of  the  cahbre  of  the  aorta  in  many  cases.  Sometimes  it  was  reduced 
even  to  a  mere  slit. 

A  cure,  however,  is  possible  even  in  cases  with  very  advanced  de- 
formitv.  This  cure  can  come  about  in 
one  of  two  ways:  (i)  By  ankylosis  be- 
tween the  surfaces  of  the  bodies  of 
the  diseased  vertebra; — a  very  slow 
process,  which  requires  years  for  its 
completion ;  (2)  by  the  deposit  of  bone 
in  the  inflammatory  material,  thrown 
out  around  the  colunin  b}-  the  action 
of  the  formative  ostitis  which  accom- 
panies the  destructive  process,  the 
vertebral  column  being  supported,  as 
it  were,  in  surroundins:  bone. 


Fig.  15.— Lower  Dorsal  Reg-ion.  Extensive  tuber- 
culous softening  involving  two  vertebras  ;  inter- 
vertebral disc  destroyed.  Knuckle  very  slight, 
probably  because  the  focus  was  in  the  centres  of 
the  vertebral  bodies,  and  laterally  destruction 
was  not  complete,  a,  Tubercul<ius  cavity-,  in- 
volving centres  of  bodies  of  two  vertebra. 
(Nichols.) 


Fig.  16. — Distortion  of  Aorta.  From 
a  case  of  spinal  caries  in  an  adult. 
At  one  point  marked  constriction 
of  the  aorta.  Angular  deformity 
very  marked,  a.  Constriction  of 
aorta.     (Dwight.) 


OCCURRENCE    AND   ETIOLOGY. 

Sex.— Sex  does  not  appear  to  be  an  important  factor  in  causing 
Pott's  disease,  though  statistics  vary  somewhat. 

Age. — The  disease  is  more  common  in  childhood.     Mohr  found,  in 

'Dwight:  Amer.  Jour.  Med.  Sciences.  January.  1S97. 
-Rev.  de  Chir..  August  loth.  1SS6.  p.  671. 


24 


ORTHOPEDIC  SURGERY. 


72  cases,  that  the  disease  occurred  between  the  first  and  fifth  years  in 
29  per  cent ;  between  the  sixth  and  tenth  years  in  22  per  cent ;  be- 
tween the  eleventh  and  fifteenth  years  in  22  per  cent ;  between  the 
sixteenth  and  twentieth  years  in  16  per  cent;  and  above  the  twentieth 
year  in  11  per  cent.  Drachman  found  in  161  cases  41  per  cent  be- 
tween one  and  five  years,  and  36  per  cent  between  five  and  ten  years. 
The  oldest  patient  was  seventy- 
seven  years  of  age,  and  the  youngest 
eight  weeks.  Gibney  found  that  Zj 
per  cent  were  under  fourteen  years 
of  age ;  7  per  cent  between  fourteen 
and  twenty;   and  4  per  cent    over 


Fig.  17.— Complete  Absorption  of 
Vertebral  Bod}'.  (Warren  Mu- 
seum.) 


Fig.   18.— Complete  Bonj'   An- 
kylosis.   (Warren  Museum.) 


twenty-one.  Taylor  found  in  375  cases  that  226  were  under  five;  68 
between  five  and  ten;  and  24  between  ten  and  fifteen.' 

Localization. — Any  of  the  vertebrae  may  be  attacked,  but  in  varying 
frequency.  As  there  are  more  dorsal  vertebrae  than  either  cervical  or 
lumbar,  it  is  natural  that  the  number  of  cases  of  dorsal  disease  should 
be  greater  than  in  the  other  regions.'^  Dollinger  in  538  cases  deter- 
mined the  vertebrae  originally  affected  to  be  as  follows :  cervical,  63 ; 
dorsal,  321;  lumbar,  154.  The  most  frequent  seat  was  between  the 
twelfth  dorsal  and  first  lumbar.  The  upper  half  of  the  column  was 
-affected  primarily  only  117  times.  In  a  series  of  1,355  cases  from  the 
Hospital  for  the  Ruptured  and  Crippled,  the  distribution  was  as  fol- 
lows: cervical,  100;  dorsal,  854;  lumbar,  317. 

Although,  as  is  seen,  the  locations  of  relative  frequency  given  by 
the  different  observers  do  not  agree,  it  would  appear  that  certain  por- 

1  New  York  Med.  Record,  August  13th,  1881. 
^Disse:  "  Skeletlehre."  1S96. 


TUBERCULOUS  DISEASE   OF   THE  SPINE. 


25 


tions  of  the  spine  are  more  liable  to  attack  than  certain  others,  and 
that  the  regions  most  liable  to  the  disease  were  those  which  were  the 
most  exposed  to  jars  or  increased  pressure ;  and  that  the  disease  would 
be  more  frequent  where  the  hinges  of  motion  at  the  spinal  column 
came,  varying  to  a  degree  according  to  age  and  occupation,  or  where 
there  was  the  greatest  exposure  to  the  effects  of  violent  jars. 

Causation. — It  may  thus  be  assumed  that  the  localizing  cause  of 
Pott's  disease  is  jar  or  superincumbent  pressure;  the  influential  cause 
being  that  physical  state  which  is  incapable  of  resisting  slight  trauma, 
exposing  the  tissue  probably  to  the  invasion  of  the  tubercle  bacillus. 

Gibney,  in  an  examination  of  185  cases,  found  a  hereditary  tuber- 
culous taint  in  76  per  cent.  In  45  per  cent  a  weakened  condition 
from  previous  sickness  was 
found ;  and  in  22  per  cent 
both  an   inherited    and   an 


Fig.  19.— Attitude  in  Cervical  Caries 
of  onlv  Moderate  Severitv. 


Fig.  20.— Attitude  Assumed  by  Children  with 
Acute  Pott's  Disease,  and  in  Other  Cases 
Necessitated  bv  Psoas  Contraction. 


acquired  diathesis  were  found.  Taylor,  in  845  cases,  found  53  per 
cent  with  a  history  of  preceding  trauma  (Vulpius,  in  810  cases,  found 
the  same  percentage  [53];;  in  15  percent  there  was  disease  of  the 
lungs  in  nearer  or  more  distant  relatives;  in  19  per  cent  so-called  scrof- 
ula was  asserted ;  and  in  34  per  cent  a  sickly  condition.  Vulpius  found 
a  history  of  hereditary  tuberculosis  in  16  per  cent  of  his  810  cases. 

SYMPTOMS. 

Few  affections  have  a  clinical  history  which  varies  so  widely  and 
appears  under  such  different  guises  as  that  of  Pott's  disease.     The  one 


26 


ORTHOPEDIC  SURGERY. 


Fig.  21.— Attitude  in  Severe  Pott's  Disease 
with  Psoas  Contraction. 


constant  symptom,  however,  which  accompanies  all  cases  of  Pott's  dis- 
ease and  must  often  form   the   chief  reliance  in  diagnosis  is  muscular 

rigidity  at  the  affected  portion  of  the 
spine.  Just  as  spasm  of  the  joint 
muscles  is  the  constant  symptom  of 
chronic  joint  disease,  so  is  restricted 
motion  between  the  diseased  verte- 
brae the  constant  accompaniment  of 
Pott's  disease,  in  its  early  or  later 
stages. 

Typical  cases  of  Pott's  disease 
are  so  characteristic  in  their  symp- 
toms that  the  diagnosis  is  evident 
almost  at  a  glance.  The  guarded 
character  of  all  the  movements  is 
perhaps  the  most  striking  feature. 
In  walking,  in  stooping,  or  in  lying 
down,  the  spine  is  most  carefullv 
guarded  against  jar  and  against  mo- 
tion, attitudes  are  assumed  which  re- 
lieve the  \'ertebral  column  of  some  of  the  weight  of  the  body,  and  a  glance 
at  the  naked  child  shows  unnatural  modes  of  standing  and  walking. 

A  prominence  of  the  ,'-'''~^- 

vertebrae  is  ordinarily  pres- 
ent as  early  as  at  this 
stage,  and  of  tener  than  not 
pain  is  acute  and  aggra- 
vated by  motion.  Consti- 
tutional disturbance  is  also 
very  likely  to  be  present 
when  the  disease  has  been 
of  even  a  few  weeks'  dura- 
tion. Loss  of  flesh  and 
appetite  and  inability  to 
go  about  much  without 
fatigue  are  often  among 
the  first  symptoms  to  at- 
tract attention. 

Peculiarity  of  attitude 
and  gait,  muscular  stiff- 
ness, and  referred  pain  are 
the  most  prominent  of 
the  earlier  symptoms,  and 
they  may  be  present  be- 


FiG.  22.— Attitude  of  Head  in  Cervical  Pott's  Disease. 


TUBERCULOUS  DISEASE   OF   THE  SPINE. 


27 


fore  a  projection  has  l)cen  noticed.  The  importance  of  recognizing 
tliese  early  symptoms  can  hardly  be  overstated,  as  it  is  on  an  early 
recognition  of  the  affection  that  the  hope  of  a  ready  cure  is  to  be  based. 
Attitude. — The  ])eculiarity  in  attitude  noticed  early  in  the  disease  is 
due  either  to  reflex  muscular  spasm — similar  to  that  seen  in  joint  dis- 
ease— or  to  an  unconscious  effort  on  the  part  of  the  patient  to  prevent 
jar  or  any  increased  pressure  upon  the  affected  vertebral  bodies. 
These  attitudes  necessarily  vary  according  to  the  point  of  the  spine  at- 


PlG. 


23.— Lordosis    in     Lumbar    Pott's    Fig.  24.— Deformity  in  Dorsal  Pott's  Disease  Show- 
Disease,  ing  Spasm  of  Muscles. 


tacked.     In  disease  of  the  upper  cervical  region,  the  most  common  atti- 
tude is  that  of  wry -neck. 

When  the  disease  is  in  the  hnvcr  cervical  or  upper  dorsal  region,  the 
chin  is  held  somewhat  raised,  to  balance  the  weight  of  the  head  on  the 
articular  facets,  suggesting  the  position  of  a  seal's  head  when  out  of 
water.  The  spinal  cokimn  below  the  point  of  disease  is  abnormal]}' 
straight,  and  in  some  instances  curved  slightly  forward,  while  in  the 
lower  dorsal  region  an  exaggerated  backward  projection  of  the  spinous 
processes  may  be  seen ;  this  projection,  due  to  a  compensating  cur\"e, 


28 


ORTHOPEDIC  SURGERY. 


is  sometimes  so  marked  as  to  suggest  that  the  disease  has  attacked 
another  part  of  the  spine. 

In  the  middle  dorsal  region  the  attitude  to  be  noticed  most  fre- 
quently is  an  elevation  of  the  shoulders.  Temporarily  a  slight  lateral 
deviation  of  the  spine  is  to  be  seen. 

In  the  lumbar  region,  the  patients  in  the  early  stage  frequently  will 
be  noticed  to  lean  backward,  like  pregnant  women  or  adults  with  large 
abdomens.  A  peculiar  position  and  characteristic  sidling  gait,  which  is 
sometimes  seen  at  a  comparatively  early  stage  of  disease  in  the  lower 
dorsal  or  lumbar  region,  is  due  to  a  slight  contraction  of  the  psoas  and 
iliacus  muscles. 

In  a  late  stage,  when  psoas  abscess  is  present,  a  marked  contraction 
of  these  muscles  takes  place ;  but  even  when  there  is  no  evidence  of 


Fig.  25. — Acute  Pott's  Disease  ;  Supporting'  Body  by  Arms. 

existence  of  suppuration  or  of  a  psoas  abscess,  slight  inflammatory  irri- 
tation of  the  muscles  will  produce  a  limitation  to  the  arc  of  extension 
of  the  thigh  on  the  trunk. 

.  In  general,  in  addition  to  the  square  position  of  the  shoulders,  the 
peculiar  position  of  the  head,  and  the  erect  attitude  of  the  upper  part 
of  the  spine,  which  prevents  the  superincumbent  weight  of  the  trunk 
and  upper  extremities  (above  the  diseased  portion  of  the  spine)  from 
falling  forward  upon  the  diseased  vertebral  body,  the  gait  is  peculiar; 
the  patient  walks  more  on  the  toes  than  on  the  heels,  and  with  the 
knees  slightly  bent — in  such  a  way  that  all  possible  springs  may  be 
brought  into  play  to  diminish  the  jarring  of  the  spine. 


TUBERCULOUS  DISEASE   OE   THE  SPINE. 


29 


These  peculiarities  of  attitudeandposition  vary  in  severity  according 
to  the  acuteness  of  the  disease;  they  may  be  at  one  time  more  notice- 
able than  at  another.  Characteristic  also  at  this  stage  of  the  disease 
is  a  muscular  stiffness,  which  becomes  more  marked  after  the  patient 
has  been  quiet  for  a  while  (during  sleep).  The  stiffness  of  the 
limbs  diminishes  or  disappears  after  the  patient  has  moved  about.  A 
certain  amount  of  muscular  rigidity  of  the  muscles  of  the  back  will  be 
felt  on  palpation  in  affections  of  the  middle  dorsal  and  lumbar  regions; 
stooping  which  involv^es  arching  of  the  back  forward  is  difficult  or  im- 
possible in  disease  of  the  lower  spine,  and  in  attempting  to  stoop  in 


Fin.  26. — .Sei'ere  Grade  of  Psoas  Con- 
traction. 


Fig.  27.— Lateral  Deviation  of  Spine 
from  Dorsal  Pott's  Disease. 


order  to  pick  up  any  article  from  the  floor  the  patient  will  keep  the 
spine  erect  and  reach  the  floor,  lowering  himself  with  an  erect  trunk, 
by  bending  the  knees. 

It  will  often  be  noticed  that  children  become  tired  more  easily  than 
usual,  and  after  playing  about  for  a  time  will  desire  to  lie  down,  to  rest 
their  arms  upon  a  chair  or  seat,  or  to  support  the  head  with  their  hands, 
or  the  trunk  by  holding  on  to  the  thighs,  according  to  the  part  of  the 
spine  affected. 

The  amount  of  muscular  stiffness,  rigidity,  and  difficulty  in  main- 


ORTHOPEDIC  SURGERY. 


taining-  the  spine  erect  is  in  a  measure  an  index  of  the  degree  of  activ- 
ity of  the  disease.  In  early  cases  the  muscles  on  either  side  of  the  area 
of  the  affected  vertebrae  will  often,  on  bending  the  back,  be  seen  to 
spring  out  in  relief,  acting  like  physiological  splints  to  the  diseased  \-er- 
tebral  column. 

Various  modifications  of  characteristic  attitudes  are  at  times  pro- 
duced. The  most  common  of  these  probably  is  the  flexion  of  the  thigh 
which  results  from  psoas  contrac- 
tion, usually  the  result  of  psoas 
abscess.  The  contraction  of  the 
muscle  is  both  the  warning  and  the 
accompaniment  of  the  abscess.  It 
may  be  present  to  such  a  degree 
that  the  leg  cannot  be  put  to  the 
ground  in  walking  and  the  use  of  a 
crutch  is  necessitated. 


Fig.  28.— Lateral  Deviation  of  Spine  in 
Dorsal  Pott's  Disease.     Back  view. 


Fig.  29. — Lateral  Deviation  of  Spine  in 
Lumbar  Pott's  Disease. 


"  Lateral  deviation  of  the  spine  is  an  attitude  to  be  found  in  Pott's 
disease  and  is  discussed  in  its  relation  to  lateral  curvature  under  the 
head  of  diagnosis.  As  a  rule,  the  lateral  curve  of  Pott's  disease  is  char- 
acterized by  very  slight,  if  any,  rotation  of  the  spinal  column  on  a  ver- 
tical axis.^ 

The  lateral  deviation  has  no  especial  significance  except  in  indicat- 
'  Annals  of  Surgeiy.  July.  1SS9. 


TUBERCULOUS  DISEASE   OF   THE  SPINE.  31 

ing  a  certain  modification  of  treatment  to  be  considered  later.  It  is 
most  severe  in  acute  cases.  The  divergence  may  reach  8°  from  the 
perpendicular  at  its  ma.ximum  point/  and  in  thirty  cases  measured  by 
the  writers  did  not  exceed  this;  5°  makes  a  divergence  enough  in 
amount  to  make  the  fitting  of  apparatus  difficult.  This  divergence  is 
diminished  b}'  the  recumbent  position.  It  is  sometimes  the  first  symp- 
tom of  Pott's  disease,  and  one  which  has  attracted  but  little  attention. 

Pain. — In  certain  cases  of  Pott's  disease  pain  is  absent  altogether, 
but  it  is  often  present  to  a  most  distressing  degree,  and  it  forms  a  more 
prominent  symptom  than  it  does  in  hip  disease  or  tumor  albus,  for  in- 
stance. In  a  measure  it  tends  to  mislead  both  parents  and  physician, 
for  the  pain  is  rarely  complained  of  in  the  back,  but  is  referred  to  the 
peripheral  ends  of  the  nerves,  and  is  thus  described  as  being  felt  in  the 
abdomen,  chest,  or  limbs.  Chipault  has  described  a  class  of  cases  in 
which  severe  pain  in  the  kyphus  is  present,  and  has  given  to  the  con- 
dition the  name  "  apophysalgie  Pottique."  "     Abdominal  pain  passes  for 


Fig.  30. — Case  of  Neglected  Pott's  Disease  with  Psoas  Contraction  and  Severe  Deformit}-. 

"stomach-ache,"  and  pains  in  the  limbs  for  "growing  pain"  or  rheu- 
matism. In  general,  it  may  be  said  here  that  persistent  localized  pain 
in  the  case  of  a  child  is  a  symptom  demanding  very  great  attention. 

The  sleep  of  these  children  is  apt  to  be  much  disturbed  by  pain,  for 
the  suffering  from  Pott's  disease,  like  all  the  pain  of  bone  diseases,  is 
more  severe  at  night.  In  the  milder  cases  this  is  manifested  by  simple 
restlessness,  while  in  more  severe  cases  it  takes  the  form  of  cr\"ing 
spells.  This  may  even  be  the  case  when  the  children  can  walk  about 
without  pain  during  the  day.  As  a  rule  the  pain  is  aggravated  by  ex- 
ercise, jars,  and  wrenches.  It  is  not  always  elicited  by  pushing  down 
on  the  child's  head.  Superficial  sensitiveness  over  the  spinous  proc- 
esses is  not  a  symptom  of  Pott's  disease. 

The  pain  is  usually  subacute,  and  may  be  only  occasional.  At 
times  the  attack  may  be  very  severe,  accompanied  by  intense  hypera^s- 
thesia,  so  that  the  pressure  of  the  bedclothes  cannot  be  tolerated,  and 
patients  in  this  condition  have  been  supposed  to  have  intense  peritoni- 
tis or  pleurisy.     The  subacute  form  is  more  common,  and  this,  togeth- 

'Orth.  Trans.,  iii.,  1S2.  -"Trav.  de  Neurologic  Chir.."  1S9S. 


32 


ORTHOPEDIC  SURGERY 


er  with  muscular  stiffness,  often  gives  rise  to  a  diagnosis  of  rheuma- 
tism, sciatica,  or  neuralgia.  Analogous  to  these  attacks  of  pain  are 
disturbances  of  the  functions  of  other  nerves — manifested  in  cough, 
peculiar  grunting  respiration,  dyspnoea  with  cyanosis,  gastric  disorders, 
obstinate  and  recurring  vomiting,  and  troubles  of  the  bladder,  with  or 
without  pain  at  the  end  of  the  penis.  Patients  suffering  in  this  way 
have  been  treated  for  bronchitis, 
pneumonia,  gastritis,  or  cystitis. 
In  one  notable  instance  the  op- 
eration   for    stone    in    the   blad- 


FiG.  31. — Result  in  Severe  Case  of  Dorsal 
Pott's  Disease. 


Fig.  32. — Dorsal  Pott's  Disease  with  Marked 
Kyphosis  and  Backward  Projection  of 
Spine. 


<3er — lateral  cystotomy — was  performed.  No  vesical  trouble  was  dis- 
covered, but  at  the  autopsy  disease  of  the  lumbar  vertebras  was 
found. 

These  periods  of  suffering  may  become  intense — constituting  acute 
attacks,  subsiding  after  rest,  and  recurring  at  intervals  without  appar- 
ent exciting  cause. 

Eye  symptoms  may  exist  in  Pott's  disease.     Partial  dilatation  ex- 


TUBERCULOUS  DISEASE   OE   THE  SPINE. 


33 


isted  in  thirty-six  out  of  thirty-eight  cases  reported  by  15ull,  and  neuri- 
tis and  optic  atrophy  have  been  reported.' 

It  is  to  be  expected  that  pain  will  be  diminished  and  general)}-  con- 
trolled by  efficient  mechanical  treatment.  Certain  cases,  however,  are 
from  the  first  so  intractable  that  pain  persists  in  spite  of  all  that  can  be 
done.  Fortunately  such  cases  are  not  the  rule,  and  in  general  it  may 
be  assumed,  when  pain  comes  on  in  the  course  of  treatment,  that  the 
apparatus  does  not  fit,  if  mechanical  treatment  is  used,  or  that  the  pa- 
rents are  not  careful  in  the  nursing  of  the  child  or  in  carrying  out  treat- 
ment thoroughly.  In  a  few  instances  it  will  be  found  that  pain  cannot 
for  a  time  be  entirely  checked  by  treatment.  A  sudden  and  violent 
increase  of  pain  should  lead  one  to  suspect  an  approaching  access  of  the 
disease — with  increase  of  the  deformity — the  formation  of  an  abscess, 
or  the  beginning  of  parahsis.     In  cases  in  which  recovery  from  Pott's 


Fig.  33.— Method  of  Measurement  o£  Deformity  in  Pott's  Disease.     Shows  lead  strip  and  card- 
board tracing.     (Children's  Hospital  Report.) 

disease  has  occurred  with  great  deformity,  the  lower  ribs  may  have 
sunk  below  the  crest  of  the  ilium,  and  by  rubbing  against  it  may  cause 
severe  pain. 

Deformity. — The  most  characteristic  feature  of  Pott's  disease  is  the 
deformity — that  is,  the  projection  backward  of  one  or  more  spinous  proc- 
esses. This  is  occasioned  by  the  destruction  of  the  vertebral  bodies. 
The  projection  is  primarily  of  the  vertebrae  first  affected,  but  following 
this  other  vertebrae  are  more  or  less  involved,  and  the  curve  increases, 
with  the  establishment  of  secondary  curves.  The  sharper  the  projec- 
tion, as  a  rule,  the  more  acute  is  the  process ;  but  this  rule,  however 
true  in  the  upper  dorsal  region,  has  occasional  exceptions  in  the  lower 
dorsal  and  upper  lumbar  regions.  It  may  be  stated  that  in  old  cases 
there  is,  as  a  rule,  more  of  a  curve  and  less  of  an  angle.  It  is  not  abso- 
lutely true  that  the  greater  the  amount  of  the  disease  the  greater  the 
'  Knies  :  "  Das  Sehorgaa  und  seine  Erkrankungen,"  1S93,  p.  205. 
3 


34 


ORTHOPEDIC  SURGERY. 


deformity,  for  there  may  be  extensive  disease  on  the  front  of  several 
bodies  without  diminishing  the  weight-bearing  function  of  all  of  them ; 
but,  generally,  the  more  vertebrae  involved  the  greater  is  the  projec- 
tion. 

It  is  most  important  to  keep  a  record  of  the  deformity  in  each  case 
under  observation.  This  record  is  most  easily  taken  by  a  simple 
method. 

A  strip  of  sheet  lead  half  an  inch  wide,  of  the  quality  known  to  the 
dealers  as  "four  pounds  to  the  foot,"  is  made  straight  by  pressing  out 
the  curves,  and  is  laid  along  the  spinous  processes  of  the  child,  who  lies 
on  his  face  on  a  flat  table  without  a  pillow,  with  his  hands  at  his  sides 


AU6.29.f883 
rE;B.6,i883 

JUNtlB85\  '  MAR  30  1877  ' 

APR.  1887 

FE8Y.30.I87II 


C    D     E 

Fig.  34.— Tracings  of  the  Deformity  in  Pott's  Disease.     A  B,  not  treated  ;  C D  E,  patient  did 
not  continue  treatment ;  F  G  H,  patient  discontinued  treatment.     (H.  L.  Taylor.) 


and  his  head  turned  to  one  side.  With  the  fingers  the  lead  is  pressed 
against  the  spinous  processes,  and  when  it  is  removed  it  is  stiff  enough 
to  keep  its  shape.  The  curve  is  then  drawn  upon  a  piece  of  cardboard 
bv  means  of  this  lead  strip,  placed  on  its  side  and  used  as  a  ruler.  The 
cardboard  curve  is  cut  out  with  scissors  and  the  concavity  is  then  ap- 
plied to  the  child's  back  to  see  if  it  fits  accurately.  If  not,  it  should  be 
trimmed  with  the  scissors  until  it  does.  The  slightest  change  in  the 
outline  of  the  back  can  then  be  detected  at  any  subsequent  visit,  be- 
cause any  increase  or  diminution  of  the  deformity  will  cause  the  card- 
board cutting  to  fit  the  outline  of  the  back  imperfectly. 

If  the  deformity  is  left  to  itself,  its  tendency  is  to  increase  until  a 
spontaneous  cure  results  or  death  ensues.  In  many  cases  in  dorsal 
Pott's  disease  this  result  is  reached  only  after  an  enormous  deformity 
has  occurred.     In  cervical  and  lumbar  Pott's  disease  spontaneous  cure 


TUBERCULOUS  DISEASE  OF   THE  SPINE. 


35 


is  more  likely  to  occur,  and,  when  it  occurs,  is  accompanied  by  much 
less  deformity  than  in  the  dorsal  region. 

When  this  spontaneous  cure  occurs,  the  change  takes  place  gradu- 
ally and  does  not  cause  narrowing  of  the  spinal  canal.  The  gibbosity 
is  most  marked  in  disease  of  the  upper  dorsal  region,  and  least  in  the 
lumbar  region.  The  secondary  curvatures  are :  in  cervical  Pott's  dis- 
ease, a  dorsal  incurvation  below  the  disease,  with  a  slight  lumbar  ex- 
curvation;  in  dorsal  disease, 
an  increased  hollowing  in 
above  and  below  the  gibbosi- 
tv  of  the  disease;  in  lumbar 
disease,  a  long  curvature  with 
convexity  inward  above  the 
disease.  The  neck  becomes 
shortened  and  thickened  in 
cervical  Pott's  disease ;  the 
trunk  is  shortened  in  disease 
of  other  parts  of  the  spine ; 
there  is  also  in  cases  of  long 
duration  a  diminution  of  an 
uncertain  origin  in  the 
growth  of  the  whole  body,  so 
that  adults  recovered  from 
Pott's  disease  of  ordinary 
severity  are  usually  of  less 
than  average  height.  In  se- 
vere cases  the  limbs  more 
usually  grow  nearer  to  the 
normal  amount,  and  are  nec- 
essarily out  of  proportion  to 
the  length  of  the  trunk. 

Taylor '  has  formulated 
the  retardation  of  growth  in 
patients  with  Pott's  disease 
as  follows : 

"  Disease  of  the  cervical  region  is  least  harmful  in  this  regard ;  dis- 
ease of  the  dorsal,  especially  the  lower  half,  the  most  so;  while  disease 
of  the  lumbar  region  occupies  an  intermediate  position.  An  average 
growth  of  an  inch  to  an  inch  and  a  half,  extending  over  a  number  of 
years,  instead  of  the  normal  two  inches  and  upward,  is  fairly  satisfac- 
tory for  patients  under  treatment  or  soon  after  the  active  stage  of  the 
disease.     A  growth  of  one  and  one-half  to  two  inches  for  a  similar  pe- 

'H.  L.Taylor:  Transactions  of  the  American  Orthopedic  Association,  xi., 
p.  197. 


Fig.  33. 


36 


ORTHOPEDIC  SURGERY. 


riod  indicates  that  disease  is  arrested  or  is  retrogressive;  in  other 
words,  that  the  case  is  doing  well.  Very  slow  or  absent  growth  indi- 
cates progressive  disease  or  impaired  vitality.  Intercurrent  disease  or 
too  long  absence  from  surgical  supervision  is  often  followed  by  a  dimi- 
nution of  the  growth  rate." 

An  alteration  in  the  shape  of  the  lower  part  of  the  face  takes  place 

in  marked  dorsal  disease, 
with  a  facial  expression 
which  is  characteristic. 

Cases  in  which  the  de- 
formity is  rapidly  increas- 
ing are,  as  a  rule,  charac- 
terized by  much  pain. 

Deformit3'.of  the  chest 
is  a  constant  accompani- 
ment of  dorsal  Pott's  dis- 
ease. The  vertebral  col- 
umn cannot  gi\'e  wa}''  and 
form  an  angular  deformit}" 
without  altering  the  posi- 
tion of  the  sternum  and 
ribs.  The  deformity  is 
usually  a  thrusting  down- 
ward and  forward  of  tlie 
sternum  with  a  lateral  flat- 
tening of  the  chest.  In 
short,  it  results  in  the  for- 
mation of  a  pigeon-breast. 
There  mav,  however,  be  a 
prominence  of  the  ribs  on 
both  sides  of  the  sternum, 
where  a  depression  of  the 
sternum  is  seen.  Some- 
times the  pigeon-breast  is 
the  first  symptom  to  attract  the  attention  of  the  parents,  and  for  that 
alone  the  children  are  brought  to  the  surgeon. 

High  Temperature. —  Cases  with  Pott's  disease  not  infrequently  have 
an  elevation  of  the  temperature  in  the  afternoon.  This  temperature  is 
diminished  or  often  reduced  to  normal  in  cases  under  bed  treatment. 
The  rise  of  temperature  is  from  one  to  three  degrees  in  average  cases 
and  occurs  independently  of  abscesses.  This  statement  rests  on  ten 
hundred  and  fifty  observations  made  at  the  surgical  out-patient  depart- 
ment of  the  Children's  Hospital.' 

'  Amer.  Jour.  Med.  Sciences.  December,  1S91. 


A 


/ 


Tig.  36. 


-Rounded  Deformity  from  Old  TX'sease  in  the 
Dorsal  Region. 


TUBERCULOUS   DISEASE   OE    THE  SPINE. 


37 


General  Condition. — Pott's  disease  j^rocluces  a  more  profound  im- 
pression upon  the  general  condition  than  do  the  other  tuberculous  joint 
and  bone  diseases.  The 
children  affected  are 
frequently  fi'etful  and 
c  a  }:)  r  i  c  i  o  u  s  ,  made  s( ) 
either  b\'  the  disease 
and  1)\'  ill-health  or  by 
injudicious  }K'tting'  on 
the  part  of  the  family. 
They  are  also  often  pre- 
cocious and  their  mental 
development  is  superior 
to  that  of  healthy  chil- 
dren of  the  same  age. 
The\"  are,  moreover,  deli- 
cate, take  cold  easily,  and 

seem    especiall}'  liable  to        fig.  37.— Tracings  from  Cases  of  Potfs  Disease  Showing 
slight     attacks'  of     pneu-  ^^^    Recession    of    the    Deformity    under     Mechanical 

•^  '        -t  Treatment. 

monia.       Patients     with 

Pott's  disease  are  of  course  liable  to  attacks   of  tuberculous  menin- 
gitis, but  the   experience  of  the   writers   would  lead   them   to  believe 

that  the  liability  to  this  was 
less  than  in  hip -joint  dis- 
ease. Necrosis  of  the  ribs  is 
one  of  the  more  uncommon 
complications. 


COMPLICATIONS. 

Paralysis. — Partial  or  com- 
plete paralysis  of  the  legs  is  a 
frequent  complication  of  Pott's 
disease.  It  may  occur  in  early 
or  late,  in  mild  or  severe  cases, 
and  no  apparent  exciting  cause 
can  be  assigned  for  its  ap- 
pearance. 

The  clinical  picture  is 
what  one  would  expect  from 
a  consideration  of  the  patho- 

FIG.  38. -Depression   of   Sternum  in  Dorsal  Potfs     ^Offical    COIlditiOH  ;    a    paralysis 

Disease.  of  motioii  mild  or  severe,  fol- 


38  ORTHOPEDIC  SURGERY. 

lowed,  if  the  case  gets  worse,  by  more  or  less  paralysis  of  sensation. 
The  motor  paralysis  varies  from  mere  muscular  weakness  to  complete 
loss  of  power.  It  begins  as  a  sense  of  fatigue,  a  dragging  of  the  feet ; 
then  there  is  inability  to  hold  one's  self  erect.  Unless  the  disease  is 
in  the  lumbar  region,  the  reflexes  are  exaggerated,  and  muscular 
spasms  may  start  from  the  least  irritation;  they  frequently  appear 
spontaneously.  In  severe  cases  the  muscles  are  flaccid  and  the  legs 
may  be  powerless.  With  the  secondary  degenerations  in  the  cord, 
rigidity  sets  in.  The  bladder  and  rectum  are  paralyzed  toward  the  end 
of  all  severe  cases,  and  whenever  the  lumbar  enlargement  is  involved  ; 
in  milder  cases  they  escape.  The  arms  are  paralyzed  in  certain  in- 
stances of  dorsal  Pott's  disease.  Of  the  sensory  paralysis  below  the 
lesion  there  is  less  to  be  said ;  it  is  apt  to  begin  as  paraesthesia ;  anaes- 
thesia afterward  may  come  on  to  a  greater  or  less  extent.  Trophic 
disturbances  are  not  to  be  seen  unless  in  exceptional  cases. 

The  wasting  of  the  muscles  and  diminution  of  electric  contractility 
are  usually  only  such  as  disuse  would  cause. 

In  a  few  instances  affections  of  the  joints,  supposed  to  be  second- 
ary to  lesions  of  the  cord,  have  been  noted,  and  instances  are  men- 
tioned in  which  herpes  zoster,  apparently  due  to  the  same  cause,  was 
present. 

Paralysis  is  rarely  an  early  symptom  in  Pott's  disease,  though  it  has 
been  observed  before  the  stage  of  deformity.  The  frequency  of  paraly- 
sis is  indicated  by  the  figures  collected  in  700  cases  observed  by  Bol- 
linger. Forty-one  cases  of  paralysis  were  noted  (5.8  per  cent).  In  26 
of  the  41  cases  the  disease  involved  the  region  from  the  third  to  the 
seventh  dorsal  vertebrae  inclusive. 

Paralysis  is  usually  bilateral ;  it  ma)-,  however,  be  unilateral,  and  in 
some  unusual  instances  it  occurs  above  the  point  of  deformity.  Tay- 
lor and  Lovett '  found,  in  an  examination  of  59  cases  of  paralysis  (out 
of  445  cases  of  Pott's  disease),  that  the  location  of  disease  was  as  fol- 
lows: I  cervical,  7  cervico-dorsal,  37  dorsal,  7  dorso-lumbar,  4  lumbar, 
3  unclassified.  The  deformity  was  large  in  20,  medium  in  10,  small  in 
17  (in  12  unclassified).  The  paralyzed  cases  presented  no  worse  de- 
formity than  that  seen  in  average  cases.  In  26  the  outline  of  the  de- 
formity was  rounded  and  gradual;  in  16  it  was  distinctly  sharp.  The 
paralysis  occurred  on  the  average  about  two  years  after  the  beginning 
of  the  disease.  It  came  on  immediately  after  a  fall  in  4  cases.  The 
duration  of  the  paralysis  was  never,  in  the  cases  reported,  over  three 
years,  except  in  one  case,  when  it  persisted  with  but  little  improvement 
for  six  years ;  in  2  cases  it  lasted  three  years ;  in  5  cases  it  lasted  two 
years.  A  recurrence  of  the  paralysis  was  noted  in  6  cases,  4  having 
two  attacks  and  2  having  three.  Out  of  209  cases  collected  by  Myers, 
'  Med.  Rec,  1SS6,  xxix.,  699. 


TUBERCULOUS  DISEASE   OF   THE  SPINE. 


39 


in  105  the  paralysis  accompanied  disease  above  the  eighth  dorsal  verte- 
bra.    Recurrence  is  not  an  unusual  feature  in  its  history. 

Paralysis  is  not  a  common  occurrence  in  Pott's  disease  under  effi- 
cient protective  treatment.  Its  prognosis  is  extremely  favorable  in 
mild  cases,  or  in  severe  ones  if  they  can  be  treated  early.  Recovery, 
when  it  occurs,  is  generally  complete,  leaving  no  trace  of  the  disability 
of  the  limbs. 

Abscess. — In  most  cases  of  Pott's  disease,  especially  in  those  under 
efficient  treatment,  the  whole  course  is  run  without  any  evidence  of 
suppuration,  but  in  others  abscesses  form  a  distressing  complication. 

The  earlier  treatment  is  begun  and  the  more  efficiently  it  is  carried 
out,  the  less  liable  are  abscesses  to  form ;  but  it  must  not  be  assumed 
that  the  occurrence  of  abscesses  is  evidence  of  incomplete  treatment. 
In  certain  cases  of  severe  disease  an  abscess  cannot  be  avoided. 

The  causes  of  the  development  of  an  abscess  are  the  same  in  Pott's 
disease  as  in  bone  tuberculosis  elsewhere.  What  the  abscess-determin- 
ing influences  are,  which  in  some 
instances  give  rise  to  profuse  suppu- 
ration and  the  absence  of  which  in 
other  cases  allows  immunity,  is  at 
present  conjectural.  They  may  be 
supposed  to  be  dependent  on  the 
amount  of  constitutional  or  local 
power  of  resistance  on  the  part  of  the 
patient,  the  extent  of  the  bacillary 
invasion,  the  severity  of  a  previous 
injury,  and  the  individual  degree  of 
recuperative  power  or  of  reparative 
tissue  development.  If  we  consider 
the  situation  of  the  vertebral  bod- 
ies (the  point  of  origin  of  abscesses) 
— projecting  into  the  cavities  of  the 
thorax  and  abdomen,  surrounded  by  the  lungs  and  intestines,  close  to 
the  large  vessels  and  the  oesophagus — it  will  seem  extraordinary  that 
the  formation  of  an  abscess  does  not  more  frequently  lead  to  a  fatal 
termination.  In  fact,  however,  the  fluid  contents  of  the  abscesses  fol- 
low in  the  line  of  least  resistance,  and  the  layers  of  fascias  in  most 
cases  protect  the  larger  cavities  of  the  trunk  from  invasion ;  the  pus 
generally  extends  to  the  surface  at  points  distant  from  its  origin,  ap- 
pearing in  the  neck,  in  the  lumbar  region,  in  the  groin,  or  in  Scarpa's 
triangle. 

Psoas  abscess  is  the  most  common.  It  is  very  rarely  met  with  in 
children  unless  in  connection  with  vertebral  disease,  but  in  general  it 
is  an  almost  pathognomonic  sign  of  dorsal  or  lumbar  Pott's  disease. 


Fig.  39.. 


Diagram  of  Abscess  from  Pott's 
Disease. 


40 


OR  THOPEDIC  S  UR  GER  \\ 


The  abscess  tends  to  enlarge  more  on  its  outer  than  on  its  inner 
side  because  the  fascia  is  less  resistant  there.  It  finally  reaches  Pou- 
part's   ligament    and   bulges    in    the  groin.     The   pus  may,  however, 


Fig.  40. — Psoas  Abscess. 

travel  as  far  down  as  the  insertion  of  the  psoas  muscle.  There  is  then 
a  swelling  both  above  and  below  Poupart's  ligament,  and  fluctuation 
may  be  detected  between  the  two  b}"  placing  one  finger  above  the  liga- 
ment and  the  other  below  it. 

Pus  may  find  its  way  to  the  iliac  fossa  either  from  a  psoas  abscess 
or  directlv  from  the  diseased  bodies.     At  times  a  collection  of  pus  will 


Fig.  41. — Psoas  Abscess. 


work  over  the  crest  of  the  ilium  or  through  the  sacro-sciatic  foramen 
and  point  in  the  gluteal  region. 

Abscesses  may  accumulate  in  the  inguinal  region  above  Poupart's 
ligament,  simulating  hernia.     Before  passing  down  the  sheath  of  the 


TUBERCULOUS  DISEASE   OF   THE  SPINE. 


4i 


psoas  muscle,  they  may  enlarge  in  the  abdominal  cavity  beneath  the 
peritoneum,  constituting  a  layer  of  subperitoneal  abscesses.  In  time 
these  abscesses  descend  down  llie  thigh,  but  they  may  remain  for  a 
long  time  large,  threatening,  abdominal  tumors. 

A  lumbar  abscess  is  the  outcome  of  disease  of  the  lumbar  vertebrae. 
It  appears  as  a  swelling  in  the  loin  on 
one  side  or  the  other  just  outside  the 
quadratus  lumborum.  At  times  it  is 
associated  with  dorsal  disease  and  not 
with  lumbar. 

Abscess  in  dorsal  disease  may  pass 
l)ctween  the  ribs  and  appear  as  a  tumor 
on  one  side  of  the  spine,  or  the  accu- 
mulation of  pus  may  remain  in  the 
posterior  mediastinum,  giving  rise  to 
cough  and  d)spnoea,  and  ma}'  be  de- 
tected as  an  area  on  one  side  of  the 
spine,  dull  to  percussion. 

rivTvW?'/ abscess  appears  as  a  tumor 
at  the  side  of  the  neck,  simulating  the 
ordinary  deep  cervical  abscess,  or  it 
may  appear  as  a  bunch  at  the  back 
of  the  pharynx,  causing  diflficult}-  in 
breathing  and  swallowing.  The  latter 
is  known  as  a  rctrop/iaryjig-cal  ^h'~>ct<>^. 

Abscesses,  however,  may  burst  into 
the  mouth,  trachea,  bronchi,  medias- 
tinum, oesophagus,  or  pleura.  They 
may  rupture  into  the  intestines,  blad- 
der, vagina,  rectum,  or  the  abdominal 
cavity ;  and  one  case  is  reported  in 
which  a  spinal  abscess  simulated  a  fis- 
tula in  ano.  Abscesses  may  also  burst 
into  the  spinal  canal  or  the  hip- 
joint.  Occasionally  they  burst  in 
the  alimentary  canal,  not  so  rarely 
in  the  lungs,  and  exceptionally  in  the  peritoneum  or  larger  vessels. 

Abscesses  in  the  lung  give  rise  to  less  disturbance  than  would  be 
supposed ;  in  reality  they  present  the  rational  and  physical  signs  of  a 
low  form  of  localized  pneumonia,  of  a  chronic  or  subacute  type.  The 
bursting  of  an  abscess  into  the  bronchi  is  characterized  by  the  discharge 
of  a  large  quantity  of  pus,  which  is  coughed  up,  the  amount  of  dysp- 
noea, collapse,  and  danger  from  suffocation  being  dependent  on  the  size 
of  the  abscess.     The  sudden  discharge  of  pus  is  the  indication  of  rupt- 


FlG.  42. — Lumbar  Abscess. 


42  ORTHOPEDIC  SURGERY. 

ure  into  the  oesophagus,  intestines,  and  bladder ;  rupture  into  the  ves- 
sels will  necessarily  be  fatal.  No  symptoms  can  be  relied  upon  to  give 
warning  of  the  impending"  danger. 

The  course  of  an  abscess  is  toward  absorption  or  increase.     It  may 
remain  stationary  in  size  and  quiescent  for  a  long  time — a  condition  of 


Fig.  43.— Cervical  Abscess. 

things  which  may  be  compatible  with  fair  general  health.  Instances 
are  not  uncommon  in  which  adults  have  been  able  to  attend  to  active 
work  and  children  to  play  about,  although  suffering  from  large  cold 
abscesses. 

When   absorption   takes   place   the   fluid  contents  disappear,  and 
the  caseous  and  purulent  detritus,  if  present,  in  all  probability  be- 


TUBERCULOUS  DISEASE   OF   THE  SPINE. 


43 


comes  encapsulated.     This   sometimes  happens  even   in   large  psoas- 
abscesses. 

Abscess  is  most  frequent  in  disease  of  the  lumbar  region,  moderately 
frequent  in  the  dorsal  region,  and  least  frequent  in  the  cerxical  region.' 

DIAGNOSIS. 

The  ordinary  clinical  history  of  a  case  is  of  little  value  as  an  aid  in 
establishing  the  presence  of  the  disease.  It  maybe  significant  enough 
to  create  a  strong  suspicion  of  the  existence  of  vertebral  disease,  but 
without  definite  physical  signs  a 
diagnosis  of  Pott's  disease  can- 
not be  made.  Too  much  impor- 
tance must  not  be  allowed  to  the 
tendency  of  the  parents  to  at- 
tribute the  condition  to  trauma- 
tism. It  should  be  mentioned 
that  the  absence  of  pain  can  in 
no  way  be  assumed  to  show  the 
absence  of  Pott's  disease. 

The  diagnosis,  then,  must 
be  made  wholl}'  from  the  phys- 
ical examination.  The  chief  phys- 
ical signs  upon  which  one  must 
rely  can  be  divided  into  two 
classes:  {a)  those  occurring 
from  bony  destruction ;  and  (Jf)  those  dependent  upon  muscular  spasm. 

(c?)  Signs  due  to  Bony  Destruction. — Since  these  are  made  evi- 
dent by  the  presence  of  angular  deformity  of  the  spine,  which  is  the 
result  of  bony  destruction,  they  are  so  conspicuous  that  they  can 
scarcely  be  overlooked.  And  the  prominence  of  one  or  more  of  the 
vertebral  bodies,  associated  with  muscular  spasm,  is  a  positive  sign  of 
the  presence  of  the  disease,  unless  it  is  the  result  of  a  fracture  of  the 
spine,  or  in  adults  the  outcome  of  malignant  disease,  aneurism  of  the 
aorta,  or  some  similar  affection.  In  the  larger  number  of  cases,  as  they 
come  to  the  surgeon,  this  bony  deformity  has  occurred,  and  the  diagno- 
sis can  be  made  at  a  glance ;  but  the  most  important  class  of  cases,  so 
far  as  the  diagnosis  is  concerned,  are  those  in  which  bony  destruction 
has  not  yet  begun,  and  in  which  the  need  of  an  early  diagnosis  is  evi- 
dent, in  the  hope  that  it  may  lead  to  treatment  which  may  be  sufficient 
to  prevent  the  occurrence  of  deformity. 

ib)  Signs  Arising  from  Muscular  Spasm. — These  are: 

I.  Stiffness  of  the  spine  in  walking  and  in  passive  manipulation. 

^  Townsend :  Orth.  Trans.,  vol.  iv..  i66.— Ketch:  Orth.  Trans.,  vol.  iv..  200. 
— Dollinger:  "Die  Bhdlg.  der  Tub.  Wirbelentz.."  etc..  Stuttgart.  1S9S. 


Fig.  44. — Retropharj-ngeal  Abscess. 


44 


OR  THOPEDIC  S  UK  GEK  Y. 


2.  Peculiarity  of  gait  and  attitudes  assumed,  according  t(j  the  loca- 
tion of  the  disease. 

3.  Lateral  deviation  of  the  spine.' 

For  all  examinations  children  should  l)e  stripped. 

I.  Muscular  Stiffness. — On  examining  for  muscular  stiffness  of  the 
spine,  the  child  is  most  conveniently  laid  face  downward  on  a  table  or 
bed,  and  lifted  by  the  feet.  In  a  normal  back  the  lumbar  and  lower 
dorsal  spine  can  l^e  markedly  bent,  and  a  general  mobility  of  the  whole 
column  is  seen.  In  patients  in  whom  Pott's  disease  is  present  the  re- 
gion affected  is  held  rigidly  by  muscular  contraction  when  manipulation 


■ 

■ 

B  '4£li^i^»nn 

WM 

^^^H^t^  ■ 

I 

I 

^^B^^^^^^ 

'Ji 

■ 

\ 

1 

M-  m 

^^H 

^^^H 

^ 

p.1^^^^^^^1 

^^1 

1 

flH 

~~^^^B 

m  ^*te»\^ 

1 

Fig.  45. — Jiigidity  of  Spine  in  Pott's  Disease.     (Children's  Hospital  Report.) 

is  attempted.  In  certain  instances  the  erector  spinae  muscles  stand  out 
like  cords  when  the  child  is  lifted,  and  it  is  questionable  how  much  im- 
portance should  be  attributed  to  this  sign ;  it  occurs  in  cases  of  hip  dis- 
ease and  in  certain  instances  in  excitable  children  in  whom  no  joint 
disease  is  present.  Lifting  the  patient  by  the  feet  in  this  way  will 
show  the  existence  of  lumbar  or  lower  dorsal  rigidity,  but  it  does  not 
detect  high  dorsal  Pott's  disease.  In  lumbar  Pott's  disease  lateral  mo- 
bility of  the  spine,  as  well  as  antero-posterior  flexibility,  is  lost. 

2.  Peculiar  Gait  and  Attitudes. — In  considering  the  gait  as  a  diag- 
nostic symptom  of  Pott's  disease,  one  must  be  prepared  to  find  any  of 
the  characteristic  features  absent.  In  general  the  walk  is  careful, 
steady,  and  military,  and  the  steps  are  taken  with  such  care  that  jars 
to  the  spine  are  avoided ;  in  other  instances,  however,  the  child  walks 
'  Boston  Med.  and  Surg.  Jour.,  October  9th.  1890. 


TUBERCULOUS  DISEASE   OF    THE  SPINE. 


45 


with  comparative  freedom,  e\"en  when  tlK'  presence  of  the  chseasc  is 
manifest,  and  the  well-known  test  of  havin',''  the  child  i)ick  up  objects 
from  the  floor  may  fail  to  detect  anything. 

Assuming,  then,  the  extreme  importance  of  the  early  diagnosis  of 
the  disease  when  practicable,  it  becomes  necessary  to  consider  in  detail 
the  deviations  from  the  normal  signs,  according  to  the  region  of  the 
spine  affected. 

Cervical  Pott's  Disease. — The  most  common  s)'mptom  (;f  the 
disease  in  this  region,  due  to  muscular  rigidit}',  is  the  occurrence  of 


Fig.  46. — Xormal  Flexibility  of  Spine.     (Children's  Hospital  Repoi't.) 

Avrv-neck  with  stiffness  of  the  muscles  of  the  back  and  neck.  This  is 
often  accompanied  by  distressed  breathing  at  night  and  intense  occipi- 
tal neuralgia.  The  head  is  held  sometimes  in  a  much  distorted  posi- 
tion;  the  most  characteristic  attitude  is  when  the  chin  is  supported  in 
the  hand ;  and  when  the  patient  turns  sideways  to  look  at  objects,  the 
whole  body  is  turned.  In  severe  cases  one  notices  flattening  of  the 
back  of  the  neck,  with  sometimes  bony  deformity.  When  spinal  dis- 
ease occurs  in  this  region  the  early  symptoms  are  most  often  confused 
with  sprains,  muscular  torticollis,  and  inflammation  of  the  cervical  lym- 
phatic glands. 

In  disease  of  the  upper  cervical  vertebrae  the  head,  however,  ma}' 


46 


ORTHOPEDIC  SURGERY. 


\ 


be  held  sharply  flexed  and  sunk  upon  the  chest.  It  may  be  hyperex- 
tended  with  the  occiput  resting  on  the  upper  part  of  the  spine,  or  it 
may  be  held  laterally  bent. 

From  sp7'ains  the  immediate  diagnosis  is  almost  impossible.  In  the 
early  stages  of  sprains  of  the  neck  the  head  is  often  held  stiffly  and  to 
one  side ;  motion  is  resisted  and  is  painful,  muscular  spasm  is  present, 

and  in  the  case  of  children  of  unintel- 
ligent parents  the  history  cannot  be 
accepted  as  valid. 

From  true  muscular  z^ny-ncck  the 
diagnosis  is  often  extremely  difficult. 
In  congenital  torticollis  manipulation 
is    generally    not    painful,    and    one 
muscle  is  firmly  contracted  while  the 
rest  are  relaxed.     In  congenital  cases 
the  head  and  face  are  distorted,  and 
the  eyes  often  are  not  upon  the  same 
plane.     In  Pott's  disease,  on  the  other 
hand,  the  muscular  fixation  involves  all 
the  muscles,  and  movement  in  any  di- 
rection is  resisted,  and  is  more  apt  to 
be   painful.     This  applies   fairly  well 
to  cases  of  anterior  wry -neck;  but  in 
cases  in  which  the  true  muscular  tor- 
ticollis is  of  the  posterior  variety,  and 
is  due  to  a  contraction  of  the  deeper 
muscles,  the  diagno- 
sis is  much  more  dif- 
ficult,   for    no    one 
muscle  is  contracted 
and  movement  is  lim- 
ited   by    a    general 
muscular  resistance. 
The    differential 


f 


J 


N 


Fig.  47.— Child  with  Dorsal  Pott's  Disease  Picking  up  Object 
from  Floor. 


diagnosis    can    be 


most  easily  made  by 
putting  the  patient 
tt)  bed  and  seeing  if  the  application  of  extension  is  sufificient  to  over- 
come the  distortion,  as  it  will  do  in  the  course  of  a  few  days  if  due 
to  Pott's  disease.  RJicuvmtk  torticollis  simulates  cervical  Pott's  dis- 
ease so  closely  that  the  physical  signs  are  not  sufficient  at  first  to  differ- 
entiate the  affections. 

Inflainnu-itiou  of  the  lymphatic  glauds  of  the  neck  may  give  rise  to  a 
position  of  the  head  simulating  wry-neck,  associated  with  muscular  spasm. 


TUBERCULOUS  DISEASE  OE   THE  SPINE.  47 

Upper  Dorsal  Pott's  Disease. — In  this  region  detection  is  the 
most  easy  because  any  bony  destruction  at  once  results  in  angular  de- 
formity, on  account  of  the  posterior  curve  of  the  spine  in  this  part,  and 
it  is  on  this  deformity  that  one  must  depend  rather  than  on  symptoms 
due  to  muscular  stiffness. 

The  shoulders  are,  however,  held  high  and  squarely,  the  gait  is  mili- 
tary and  careful,  and  lateral  deviation  is  almost  certainly  present.  In 
Pott's  disease,  paralysis  may  exceptionally  be  the  first  perceptible 
symptom. 

From  round  shoulders,  Pott's  disease  is  generally  to  be  distinguished 


Fig.  48.— Xormal  Child  Picking  up  Object  from  Floor. 

by  the  fact  that  in  the  former  the  spine  is  flexible  and  the  deformity 
rounded  and  not  angular.     The  distinction  is  generally  easily  made. 

Lumbar  Pott's  Disease. — Vertebral  disease  in  this  region  of  the 
spine  is  difficult  of  detection  on  account  of  the  anterior  curve  of  the 
spine  in  the  lumbar  region,  so  that  in  any  moderate  amount  of  destruc- 
tion of  the  lumbar  vertebral  bodies  no  posterior  angular  curvature  is  de- 
veloped, and  it  is  only  in  the  later  stages  of  the  disease  that  any  angu- 
larity becomes  prominent.  The  occurrence  of  deformity  is  preceded  by 
a  flattening  of  the  lumbar  curve.  The  attitude  is  that  of  lordosis,  which 
in  some  cases  becomes  very  marked ;  the  gait  is  military  and  careful, 
and  lateral  deviation  is  generally  present,  sometimes  to  a  very  marked 
degree.     It  is  in  this  region  of  the  spine  that  it  is  most  conspicuous. 


48 


OK  THOPEDIC  S  UR  GER  Y. 


In  many  instances  of  lumbar  Pott's  disease  the  first  noticeable 
symptom  is  a  limp,  which  is  due  to  unilateral  psoas  contraction,  the 
result  perhaps  of  abscess  or  perhaps  only  of  psoas  irritability.  Psoas 
contraction  must  be  set  down  as  one  of  the  common  s}'mptoms  of  lum- 
bar Pott's  disease.  If  the  child  is  laid  on  its  face  and  an  attempt  is 
made  to  flex  the  lumbar  spine,  it  is  found  to  be  entirely  rigid.  Any 
attempt  to  hyperextend  the  leg  in  this  position  leads  to  the  detection 
of  the  slightest  psoas  irritability. 

Lumbar  Pott's  disease  is  occasionally  mistaken  for  single  or  double 
hip  disease,  or  is  regarded  as  a  rhachitic  curvature. 

The  differential  diagnosis  between  lumbar  Pott's  disease  and  Jiip 


Fig.  49. — Altitude  Assumed  in  Dorsal  Pott's  Disease  when  Rising'  from  Floor. 


disease  is  at  times  difficult,  although  it  is  not  generally  considered  so. 
When  the  hip  symptoms  are  due  to  Pott's  disease  and  are  caused  by 
psoas  irritability,  the  restriction  of  motion  in  the  hip  is  simply  in  the 
loss  of  hyperextension,  while  abduction  and  internal  rotation  are  free 
and  not  affected.  This  limitation  of  motion  in  only  one  direction  is 
generally  sufficient,  in  connection  with  the  other  symptoms,  to  establish 


TUBERCULOUS  DISEASE   OF    THE  SPINE.  49 

the  presence  of  Pott's  disease.  On  the  other  hand,  in  some  cases  the 
hmitation  of  the  hip's  motion  is  in  all  directions,  and  simulates  very 
closely  the  limitation  of  true  hip  disease. 

Another  element  which  leads  to  the  confusion  of  the  two  affections 
is  the  rigidity  of  the  lumbar  spine  which  often  occurs  as  an  accompani- 
ment of  acute  hip  disease.  If  a  child  with  hip  disease  is  laid  upon  its 
face,  and  an  attempt  made  to  fiex  the  lumbar  spine  by  lifting  the  feet 
from  the  table,  the  irritability  of  all  the  muscles  is  so  great  that  often 
the  lumbar  spine  will  appear  to  be  completely  rigid,  and  only  a  very 
careful  examination  will  show  that  this  is  secondary  to  the  hip  dis- 
ease. 

RJiachitic  deformity  of  the  spine  is  a  posterior  curvature  often  so 
sharp  as  to  be  angular.  It  occurs  at  the  junction  of  the  dorsal  and  the 
lumbar  regions.  This  junction  is  also  a  frequent  site  of  Pott's  disease. 
Muscular  stiffness  may  not  be  present. 


Fig.  50.  — Examination  fcr  Psoas  Contraction.     (Children's  Hospital  ]<eport.) 

Rhachitic  curvature  of  the  spine  is  characterized  by  persistent  stiff- 
ness in  most  cases,  so  that  if  the  child  is  laid  upon  its  face,  and  an  at- 
tempt is  made  to  fiex  the  spine,  the  curve  is  not  obliterated.  The 
symptoms,  therefore,  are  the  same  that  would  be  presented  by  Pott's 
disease  occurring  under  the  same  conditions,  and  much  dependence 
must  be  placed  upon  the  coexistence  of  rickets.  It  is  often  of  use  to 
treat  such  cases  by  rest  on  a  frame,  and  if  the  curve  is  rhachitic,  mo- 
bility will  be  restored  to  the  back  within  the  course  of  a  few  months. 

The  Diagnosis  of  Abscess. — The  diagnosis  of  a  well-developed  ab- 
scess in  Pott's  disease  rarely  presents  any  difficulty,  but  in  certain  in- 
stances their  occurrence  is  attended  with  peculiar  symptoms  which 
may  give  rise  to  some  obscurity.  In  the  cervical  region  the  most  com- 
mon seat  of  abscess  formation  is  in  the  back  wall  of  the  pharynx,  where 
it  often  persists  for  some  time  unrecognized,  giving  rise  to  a  peculiar 
series  of  respiratory  symptoms.  The  pharyngeal  wall  is  pushed  for- 
4 


50  ORTHOPEDIC  SURGERY. 

ward,  and  the  child  breathes  at  night  with  a  peculiar  snoring  respira- 
tion, which  is  to  a  certain  extent  characteristic.  There  is  some  diffi- 
culty in  swallowing  food  ;  the  pain  is  apt  to  be  severe ;  and  occasionally 
a  swelling  extends  so  much  to  the  side  as  to  be  noticeable  at  the  side  of 
the  neck.  The  finger  introduced  into  the  mcuth  comes  upon  a  project- 
ing swelling  of  the  back  of  the  pharynx,  which  is  characteristic  and  not 
to  be  mistaken. 

In  the  dorsal  and  lumbar  region  the  abscesses  point  for  the  most 
part  in  the  loin,  or  follow  down  the  course  of  the  psoas  muscle  to  ap- 
pear in  the  upper  part  of  the  thigh  or  groin.  Appearing  in  the  back, 
the  abscess  is  not  likely  to  be  mistaken  for  anything  unless  for  an  ab- 
scess of  the  back  muscles  or  a  lipoma. 

Psoas  abscess  causes  limitation  of  hyperextension  of  the  hip,  and 
therefore  a  limp.  In  the  iliac  fossa  a  resistant  or  fluctuating  tumor  is  to 
be  felt.  When  abscess  is  present,  if  the  child  is  laid  on  the  face,  hyper- 
extension of  the  hip  on  the  affected  side  will  be  found  to  be  limited. 

The  Diagnosis  of  Paralysis. — Paralysis  in  Pott's  disease,  although 
ordinarily  one  of  the  later  symptoms,  may  occasionally  precede  the  de- 
formity and  be  the  first  sign  of  the  presence  of  vertebral  disease. 
Such  cases  are  not  so  rare  that  they  should  be  overlooked.  The  oc- 
currence of  myelitis  in  a  young  child  should  be  considered  as  extremely 
suspicious,  and  as  being  more  likely  due  to  Pott's  disease  than  to  any 
other  cause,  even  if  the  signs  of  vertebral  disease  are  obscure  or  appar- 
ently absent.  In  general  the  paralysis  is  preceded  by  a  stage  of  the 
disease  in  which  pain  is  much  increased.  Ordinarily  one  of  the  first 
demonstrable  signs  is  an  increase  of  the  patella  reflexes,  with  perhaps 
ankle  clonus. 

Sprain. — It  is  difficult  at  times  to  differentiate  a  sprain  of  the  ver- 
tebral column  from  Pott's  disease.  After  a  fall  in  which  the  back  has 
been  wrenched,  a  child  begins  to  walk  stiffly  and  to  complain  of  pain  in 
the  back  and  perhaps  in  the  legs.  Attitudes  characteristic  of  Pott's 
disease  are  assumed,  the  trunk  is  supported  with  the  hands  upon  the 
thighs,  the  back  is  kept  stiff  in  stooping,  and  passive  manipulation 
shows  that  muscular  rigidity  is  present.  At  an  early  stage  a  diagnosis 
is  sometimes  clearly  impossible.  But  in  sprains  of  the  back  the  ten- 
dency is  to  a  rapid  recovery  under  proper  conditions,  and  the  result 
establishes  the  diagnosis.  Severe  sprains  of  the  back  are  comparative- 
ly rare  in  childhood,  but  in  adult  males  engaged  in  laborious  occupation 
cases  of  strain  are  more  common  than  cases  of  Pott's  disease.  The 
diagnosis  is  one  which  should  be  made  in  childhood  with  very  great 
reserve. 

Rotary  lateral  curvature  of  the  spine  is  an  entirely  different  affec- 
tion from  Pott's  disease.  It  is  not  the  result  of  a  tuberculous  destruc- 
tion of  bone,  but  is  the  result  of  a  distorted  and  abnormal  process  of 


TUBERCULOUS  DISEASE   OF    THE  SPINE.  51 

growth.  It  is  characterized  not  by  an  angular  projection  of  the  spine 
backward,  but  by  a  gradual  curve  of  the  s[nne  laterally  with  a  rotation 
of  the  vertebral  column  on  its  long  axis.  Pain  is  not  present,  and  the 
recognition  of  the  affqction  is  generally  due  to  an  alteration  in  the  out- 
lines of  the  trunk  and  a  prominence  of  the  shoulder  or  hip. 

In  most  cases  the  diagnosis  is  not  at  all  ob.scure.  But  in  the  course 
of  Pott's  disease  at  an  early  stage  a  lateral  deviation  may  be  present, 
which  ma)-  be  mistaken  for  lateral  curvature.  On  a  careful  examination 
it  will,  howe\-er,  be  fountl  that  a  stiffness  of  the  back  is  present  which  is 
never  seen  at  an  early  stage  of  lateral  curvature.  In  some  instances  care- 
ful and  repeated  examinations  are  needed  to  establish  a  positive  opinion. 

A  lateral  deviation  takes  place  also  sometimes  in  old  cases  of  Pott's 
disease  in  connection  with  an  old  kyphotic  curve  destruction  of  bone 
greater  at  one  side  than  at  the  other. 

Hyperaesthetic  spine,  also  termed  the  hysterical  spine  and  the  neu- 
romimetic  spine,  is  characterized  by  tenderness  in  certain  portions  of 
the  back,  sometimes  accompanied  by  pain  or  ache.  This  condition  is 
more  common  in  neurotic  persons,  but  may  be  seen  in  others  who  have 
been  suffering  from  nervous  exhaustion  from  any  cause.  It  generally 
follows  some  slight  or  severe  accident  and  as  a  rule  occurs  in  persons 
with  weak  back  muscles.  The  tenderness  may  be  intense  and  mani- 
festly exaggerated,  or  it  may  be  only  slight  and  confined  to  small  spots 
in  the  lower  cervical  and  upper  dorsal  or  in  the  upper  lumbar  region. 
As  a  rule,  no  real  stiffness  in  the  back  is  present,  but  in  severe  cases, 
or  in  cases  which  have  remained  in  bed  for  some  time,  muscular  stiff- 
ness may  be  present.  This  condition  is  sometimes  seen  after  railway 
accidents.  In  the  cases  that  are  termed  "railway  spine,"  abnormal 
projection  or  deformity  in  the  spine  does  not  exist,  although  lax  liga- 
ments and  weak  muscles  permit  a  flexed  condition  of  the  spinal  column 
in  standing,  Avhich  may  make  one  or  two  vertebrje  unduly  prominent  as 
the  patient  stands  erect,  but  this  prominence  disappears  in  recumbency. 
Referred  pains,  or  the  attitude  and  gait  characteristic  of  Pott's  disease, 
are  absent.  A  hyperaesthetic  spine  occurs  in  adults,  and  especially  in 
growing  young  girls ;  it  may  exceptionally  be  seen  in  children. 

Malignant  disease  of  the  spine  presents,  when  a  projection  is  found, 
a  more  rounded  and  less  sharp  projection  than  is  seen  in  the  beginning 
of  caries.  Carcinoma  of  the  spine  is  usually  secondary.  .  The  symp- 
toms, however  —  pseudo-neuralgias,  paresis,  paralysis,  and  muscular 
stiffness — are  the  same  in  both,  and  sometimes  only  a  conjectural  diag- 
nosis can  be  made.     Sarcoma  of  the  spine  is  very  rare  in  childhood. 

Much  the  same  may  be  said  of  the  curvatures  of  the  spine  caused 
by  aneurism,  except  that  the  diagnosis  is  usually  made  by  auscultation 
or  by  the  rational  S3'mptoms  before  the  spine  is  noticeably  affected. 
Titinors  pressing  on  the  spinal  cord  may  cause  stiffness  of  the  back 


52  ORTHOPEDIC  SURGERY. 

and  pain  referred  to  the  peripheral  ends  of  the  nerves.  Angular  de- 
formity, however,  is  absent,  and  the  symptoms  of  nervous  disturbance 
predominate  over  the  ordinary  ones  of  Pott's  disease. 

Osteomyelitis  of  the  spine  may  be  secondary  or  primary.  The 
transverse  and  articular  processes  as  well  as  the  vertebral  bodies  may 
be  affected,  and  tenderness  is  present  at  the  seat  of  disease.  Suppura- 
tion elsewhere  occurs  in  sixty  per  cent  of  all  cases.  There  is  much 
constitutional  disturbance,  fever  is  high,  and  the  course  rapid.  CEdema 
of  the  affected  parts  appears  early ;  abscesses  of  a  very  acute  and  ex- 
tensive character  as  well  as  paralysis  are  other  early  features.  The 
formation  of  a  k}'phus  of  any  extent  is  unusual. 

Spondylitis  deformans  of  the  spine  is  an  affection  most  frequent  in 
adult  life,  characterized  on  superficial  examination  by  stiffness  and 
some  arching  of  the  spine ;  there  are  usually  little  muscular  spasm  and 
no  unusual  projection  of  the  spinous  processes;  in  some  instances  the 
ribs  are  ankylosed  to  the  spine,  so  that  no  expansion  of  the  chest  is 
possible.  Stiffness  of  the  back  is  present,  but  the  whole  spine  is  rigid 
and  other  joints  may  be  involved.  These  cases  may  occur  in  connec- 
tion with  gonorrhoea.  Patients  suffering  from  this  affection  may  have 
neuralgic  or  pseudo-neuralgic  pains  of  the  nerves  issuing  from  the  spine 
at  the  affected  part. 

Spondylolisthesis,  or  dislocation  of  one  of  the  lumbar  vertebrae,  may 
cause  pain,  lordosis,  and  peculiarity  of  gait  and  posture.  There  is  no 
characteristic  kyphus  and  the  diagnostic  signs  of  spondylolisthesis  will 
establish  its  existence. 

With  regard  to  the  symptoms  of  sacro-iliac  disease,  perinephritis, 
and  appendicitis,  it  may  be  said  that  a  mistake  in  diagnosis  may  hap- 
pen, but  that  ordinarily  there  is  no  obscurity.  It  should,  however,  be 
borne  in  mind  that  in  appendicitis  and  in  perinephritis,  when  an  ab- 
scess is  present,  a  contraction  of  the  thigh  may  occur,  resembling  that 
seen  in  psoas  abscess.  The  absence  of  a  projection  or  irregularity  of 
the  back,  and  the  power  of  muscular  movement  of  the  back  in  these 
cases,  will  help  to  establish  the  fact  that  they  are  not  due  to  disease  of 
the  spine. 

Skiagrams  in  early  cases  of  Pott's  disease  rarely  aid  in  the  diagnosis, 
but  when  marked  osseous  change  has  taken  place  the  fact  may  be  seen 
in  certain  regions  of  the  back. 

PROGNOSIS. 

Pott's  disease  will  always  be  regarded  as  one  of  the  most  formidable 
of  diseases ;  its  long  course,  the  deformity  entailed,  the  severity  of  the 
complications,  and  the  occasional  termination  in  death  give  both  to  the 
surgeon  and  to  the  non-professional  public  a  natural  dread  of  the  affec- 
tion.    These  inferences  are,  however,  drawn  from  the  severer  cases, 


TUBERCULOUS  DISEASE   OF   THE  SPINE.  53 

and  facts  show  that  the  disease  has  a  tendency  to  spontaneous  recovery, 
that  in  certain  parts  of  the  spine  deformity  can  be  prevented,  and  that 
in  few  affections  does  the  work  of  the  surgeon  give  greater  rehef  than 
in  Pott's  disease. 

Mortality. — No  statistics  of  value  exist  as  to  the  percentage  of  mor- 
tahty  and  recovery. 

The  occurrence  of  severe  pain,  fever,  and  rapid  increase  of  the  de- 
formity are  unfavorable  from  a  prognostic  point  of  view.  The  general 
condition  of  the  patient  and  the  family  history  are  of  importance  in  the 
prognosis.  The  occurrence  of  paralysis  does  not  affect  the  prognosis 
unfavorably.  The  occurrence  of  abscess  makes  the  prognosis  slightly 
less  favorable,  because  abscess  accompanies  the  severer  cases. 

Forty-nine  cases  of  psoas  abscess  operated  on  at  the  Children's  Hos- 
pital in  the  decade  ending  in  1900  were  investigated  as  to  end  results  by 
one  of  the  writers.  Thirty-five  per  cent  were  known  to  have  died  and 
53  per  cent  to  be  alive  shortly  after  the  close  of  the  decade.  Of  cases 
operated  on  in  the  first  five  years  50  per  cent  were  dead,  and  of  cases 
in  the  last  five  years  26  per  cent  had  died. 

The  percentage  of  recovery,  however,  in  patients  under  better  hy- 
gienic conditions  than  hospital  patients  is  more  favorable. 

The  tendency  of  the  deformity  is  to  spontaneous  increase,  and  this 
is  specially  marked  in  the  upper  dorsal  region.  Instances  of  arrest 
without  marked  deformity  are  not  so  very  rare  in  upper  cervical  disease 
and  in  lumbar  disease,  but  in  the  upper  and  middle  dorsal  regions  the 
tendency  is  for  an  increase  of  the  deformity  proportionate  to  the  extent 
of  the  disease.  In  many  cases  some  arrest  of  the  growth  of  the  whole 
child  takes  place  apart  from  the  loss  of  vertebral  substance.  The  cure 
from  Pott's  disease  may  be  so  complete  as  to  permit  normal  childbirth, 
provided  no  distortion  of  the  pelvis  has  taken  place.' 

No  reliable  statistics  exist  as  to  the  amount  of  time  necessary  to 
establish  a  cure  in  Pott's  disease.  The  disease  varies  greatly  as  to  its 
self-limitation  in  individuals,  and  according  to  the  situation  and  extent 
of  the  disease.  Necessarily  there  will  be  a  difference  in  individual 
cases  in  the  result  of  treatment. 

It  may  be  said  that,  as  the  bodies  in  the  cervical  region  are  smaller 
than  those  in  the  lumbar,  the  time  required  for  self-limitation  here  is 
shorter  than  in  tlie  lumbar  region.  In  the  latter  region,  also,  the  super- 
incumbent weight  is  a  more  important  factor  than  in  the  upper  part  of 
the  spine. 

The  occurrence  of  bony  formation  firm  enough  to  support  the  col- 
umn in  its  weight-bearing  function  must  be  a  process  requiring  a  long 
time  for  its  completion,  to  judge  from  it  as  observed  elsewhere;  and 
nowhere  is  protection  more  urgently  demanded  during  convalescence 
'-Trans.  Amer.  Orth.  Assn..  vol.  iv. 


54  ORTHOPEDIC  SURGERY. 

than  in  the  vertebral  cokimn.  This  is  especially  true  in  growing  chil- 
dren. Cases  of  supposed  cure  of  Pott's  disease  have  redeveloped 
S}'mptoms  at  the  period  of  rapid  growth  at  the  approach  of  puberty. 
It  should  especially  be  borne  in  mind  that  protection  to  the  spine  may 
be  needed  at  this  period. 

TREATMENT. 

This  varies  according  to  the  stage  and  condition  of  the  pathological 
process. 

When  the  destructive  ostitis  is  acute  and  extensive  the  affected 
bone  should  be  protected  from  all  jar  and  pressure,  both  that  due  to 
superimposed  weight  and  attitude.  When  cicatrization  has  begun  the 
spine  should  be  protected  so  that  activity  necessary  for  health  ma}-  not 
cause  injury  in  the  imperfectl)'  healed  bone  structure. 

Protection  is  necessary  until  the  previously  inflamed  bone  has  be- 
come cicatrized  so  thoroughly  as  to  withstand  without  injury  jar  and 
superimposed  pressure. 

A  growing  spinal  column,  even  if  the  vertebras  have  recovered  from 
caries,  may  need  support  to  prevent  an  increase  of  curvature  by  abnor- 
mal growth. 

Treatment,  therefore,  is  different  in  the  acute,  the  subacute,  and  the 
convalescent  stages.  In  the  acute  stage  recumbency  is  the  most  effi- 
cient method.  In  the  subacute  and  convalescent  stage  ambulatory 
treatment  with  more  or  less  efficient  spinal  protection  is  advisable. 

Treatment  by  Recumbenxy 
If  the  patient  lies  upon  his  back  or  upon  his  face  on  a  hard  surface, 
there  is  no  superincumbent  weight  pressing  upon  anv  portion   of  the 
spine.     If  the  patient  lies  upon  his  back  upon  a  spring-bed,  and  the  bed 


Fig.  51. — Gas-Pipe  Frame. 

sags,  the  spine  is  of  course  bent,  and  pressure  upon  the  vertebrae,  pro- 
portional in  amount  to  the  extent  of  the  curve,  results. 

If  treatment  by  recumbency  is  to  be  adopted,  it  is  not  sufficient 
simply  to  place  the  child  in  bed.  Sagging  of  the  mattress,  moving  of 
the  patient  from  side  to  side,  twisting  and  turning  are  all  injurious,  in 
that  they  cause  motion  between  the  vertebrae  and  change  interarticular 
pressure,  both  of  which  are  undesirable. 

It  is  necessary  that  the  child  should  be  fixed  in  a  suitable  position 
in  bed.     This  can  be  done  bv  securing:  the  child  in  such  a  manner  that 


TUBERCULOUS  DISEASE   OF   THE  SPINE. 


55 


the  vertebral  column  at  the  seat  of  disease  is  arched  forward,  diminish- 
ing the  interarticular  j^-essure.  The  simplest  way  of  doing  this  is  by 
means  of  a  frame. 

The  rectangular  bed  frame  (Chapter  XXI.,  9)  consists  of  a 
stretcher  of  heavy  cloth  attached  to  a  rectangular  gas-pipe  frame. 

The  child  lying  upon  this  frame  can  be  secured  by  means  of  straps 
across  the  shoulders  and  pelvis  and  knees,  and  can  be  carried  about 


Fig.  52. — Mehhod  of  Securing  Child  to  Bed  Frame  for  Recumbent  Treatment  of  Dorsal  Pott's 

Disease. 

without  jar.     When  the  frame  is  placed  upon  the  bed,  the  cloth  cover- 
ing is  no  more  uncomfortable  than  the  surface  of  the  bed. 

But  simple  recumbency  is  not  alone  sufficient  to  promote  cicatricial 
ostitis.  The  removal  of  intervertebral  pressure  is  also  necessary. 
This  is  to  be  accomplished  by  arching  the  spinal  column  forward  at  the 
point  of  the  kyphotic  curve.     When  the  cicatrization  has  not  progressed 


Fig.  53.— (Jas-Pipe  Silva  Frame. 

so  far  as  to  produce  ankylosis,  correction  (partial  or  complete)  of  the 
curve  can  be  effected  by  placing  under  the  curve  of  the  child  lying  upon 
the  back  a  firm  pad,  pressing  upon  each  side  of  the  sjjinous  process, 
and  sufficiently  high  to  press  this  part  upward  while  the  rest  of  the 
spinal  column  drops  back  b\'  its  own  weight.  The  pads  can  be  fur- 
nished by  properl)'  folded  sheets  or  towels,  by  felt  padding,  or  by  a 


56 


ORTHOPEDIC  SURGERY. 


plaster-of-Paris  back  moulded  to  a  corrected  position  of  the  spine,  or  by 
arching  the  frame  at  a  desired  point,  as  has  been  suggested  by  Silva 
and  Whitman.'  This  holds  the  spine  hyperextended  throughout  its 
length.  In  this  way  greater  separation  at  the  diseased  region  is  ob- 
tained perhaps  more  easily  than  on  the  ordinary  frame.  The  ordinary 
frame,  however,  properly  padded,  answers  every  purpose. 

A  child  undergoing  treatment  on  the  frame  should  be  turned  once 
a  day  to  have  the  back  washed,  rubbed  with  alcohol,  and  powdered.  It 
is  important  that  there  should  be  no  pads  in  the  median  line  immedi- 


FlG.  54.— Traction  in  Cervical  Caries.     (Children's  Hospital  Report.) 

ately  above  or  below  the  deformity,  but  that  the  pads  should  lie  entirely 
outside  of  the  line  of  the  spinous  processes.  To  secure  better  fixation 
it  may  at  times  be  necessary  to  place  pads  under  the  lumbar  region. 

In  cervical  caries  head  traction  in  a  recumbent  position  will  be 
found  of  use  in  cases  of  torticollis ;  and  in  severe  neuralgia  from  cervi- 
cal caries  the  relief  afforded  is  often  very  marked.  Traction  can  be 
furnished  by  means  of  a  head  sling  passing  over  the  forehead  and  oc- 
ciput, which  is  attached  to  a  weight  and  pulley  running  over  the  head 
of  the  bed  or  to  the  head  of  the  frame.  The  counter  pull  may  be  fur- 
nished by  the  weight  of  the  body  in  case  the  head  of  the  bed  is  raised, 
by  a  downward  pull  upon  the  trunk  through  a  waist  band,  or  by  means 
of  traction  applied  to  the  limbs. 

Treatment  by  recumbency  will  be  found  of  service,  either  alone  or 
in  conjunction  with  other  methods,  in  cases  with  acute  symptoms,  in 
cases  of  severe  cervical  disease,  in  cases  with  marked  lateral  deviation 
'  Whitman's  "  Orth.  Surg.."  2d  ed..  p.  91. 


TUBERCULOUS  DISEASE   OF   THE  SPINE.  5/ 

of  the  spine,  in  paralysis,  in  cases  of  psoas  contraction  and  abscess,  in 
cases  which  do  not  progress  well  under  ambulatory  treatment  and 
which  lose  flesh  and  strength,  and  in  very  small  children  in  whom  the 
difficulty  of  fixing  the  spine  by  apparatus  is  great. 

Patients  who  have  been  suffering  will  often  be  found  to  gain  flesh 
after  the  relief  afforded  by  recumbency,  though  the  muscles  in  the 
limbs  diminish  in  size. 

Treatment  by  recumbency,  if  used,  should  be  thorough.  Half 
measures  have  the  evils  of  the  imprisonment  without  the  benefit  of  fix- 
ation. The  limit  of  its  usefulness  is  usually  marked  by  the  restlessness 
of  the  patient.  In  children  the  irksomeness  of  the  confinement  is 
borne  readily;  but  in  adults  the  imprisonment  constitutes  a  serious 
obstacle  to  the  employment  of  the  method. 

The  objections  to  treatment  by  recumbency  are  evident.  Pott's 
disease  is  a  tuberculous  affection  and  close  confinement  is  injurious  to 


Fig.  55. — Ward  Carriage  for  Recumbent  Treatment  of  Pott's  Disease. 

patients  with  a  tuberculous  taint.  Patients  of  this  sort  need  all  possi- 
ble help  from  fresh  air  and  exercise,  and  the  method  of  treatment  by 
recumbency  for  years,  formerly  the  only  thorough  method  possible,  is 
not  now  regarded  as  necessary  in  all  cases.  It  must  be  remembered 
that  all  apparatus  is  necessarily  imperfect  from  a  mechanical  point  of 
view  and  must  fail  in  wholly  relieving  the  diseased  vertebrae  of  their 
weight-bearing  function,  so  that  within  its  limitations  recumbency  is  to 
be  recognized  as  mechanically  the  most  efficient  mode  of  treatment  and 
the  least  likely  to  encourage  deformity. 

Ambulatory  Treatment. 

Treatment  by  Plaster  Jackets. — -The  purpose  of  the  treatment  by 
plaster  jackets  is  to  fix  the  spine  so  firmly  that  there  will  be  no  injury 
to  the  affected  vertebrae  from  the  jar  incident  to  locomotion. 


5! 


OK  THOPEDIC  S  UR  GER  Y. 


Plaster  jackets  (Chapter  XXI.,  1 )  are  made  by  applying  successive 
layers  of  properl}'  prepared  bandages  to  the  patient's  trunk,  which  has 
been  placed  in  a  suitable  position. 

The  patient  during  the  application  of  a  plaster  jacket  is  either  up- 
right or  recumbent  (on  back  or  face),  with  or  without  a  suspension  or  a 
traction  pull.  The  application  of  the  jacket  by  suspending  the  patient 
by  the  head  and  arms  was  the  method  introduced  by  Sayre,  and  has  the 

advantage  of  ready  application 
and  has  been  of  great  benefit  in 
curing  a  large  number  of  patients 
unrelieved  by  former  methods. 

Applicatiox  of  Jacket 
WITH  THE  Patient  Suspended. 
—  Suspending  a  healthy  person 
by  the  head  diminishes  the 
physiological  curves  (cervical 
and  lumbar  lordosis,  dorsal  ky- 
phosis), and  the  spine  becomes 
straight  so  far  as  its  formation 
will  allow. 

In  suspension,  in  old  Pott's 
disease,  it  is  only  the  physio- 
logical curves  which  are  obliter- 
ated ;  ■  the  sharp  kyphosis  is  held 
too  firmly  by  adhesions  to  permit 
correction.  In  earlier  cases  the 
intervertebral  pressure  is,  in  a 
measure,  diminished  at  the  point 
of  disease  by  suspension ;  but 
suspension  does  not  cause  a  dis- 
appearance of  the  sharp  angular 
projections  at   the  point   of  dis- 

PlG.  56.- Sa3-re  Headpiece  for  Suspension  in        CaSC,      although      the      kyphuS      is 
Potfs  Disease.  diminished. 

The  undoubted  beneficial  effect  of  a  plaster  jacket  is  due  to  its  ser- 
vice as  a  fixation  support  in  an  improved  position,  although  it  was  origi- 
nally supposed  that  a  jacket  could  be  applied  so  as  to  serve  as  a  means 
for  holding  the  diseased  vertebrae  apart,  i.e.,  as  a  means  of  distraction. 
The  treatment  by  plaster  jackets  requires  care,  for  a  poor  jacket  does 
harm  rather  than  good  b}'  deceiving  the  physician  and  the  patient. 
For  the  proper  applying  of  plaster  jackets,  moreover,  a  careful  atten- 
tion to  detail  is  necessary. 

The  patient's  clothes  are  removed  and  a  thin,  tightl}-  fitting  under- 
^  Anders :  Archiv  f.  klinische  Chirurgie,  i88g,  iii.,  p.  55S. 


TUBERCULOUS  DISEASE   OF    THE  SPINE. 


59 


shirt  is  applied,  put  on  so  as  to  present  no  wrinkles.  The  patient  is 
thickly  padded  by  felt  or  sheet-wadding  pads  o\'er  the  pelvis  and  two 
thick  felt  pads  are  placed  longitudinally  at  the  sides  of  the  kyphus. 
l"he  patient  is  then  suspended ;  the  head  is  secured  in  a  sling,  which  is 
attached  to  a  strong  cord  playing  in  a  pulley,  or  series  of  pulleys,  fast- 
ened to  a  point  above  the  patient's  head.  An  assistant  pulling  on  the 
cortl  raises  the  patient  so  that  the  heels  are  free  from  the  floor.  It  is 
desirable  to  diminish  the  strain  upon  the  neck,  and  padded  loops  con- 
nected with  the  bar,  which  is  raised  by  the  cord  and  pulley,  can  be 


Fig.  57.— Jury-mast  Before  Incorporation.  FiG.  58.  — Jury-mast  and  Plaster  Jacket. 

passed  under  each  axilla,  or  handles  may  be  held  in  each  hand,  con- 
nected with  cords  which  play  over  pulleys.' 

The  bandages  are  then  wound  smoothly  around  the  patient.  If 
the  plaster  is  fresh  and  of  the  best  Cjuality,  it  should  harden  in  five 
minutes.  The  hardening  can  be  hastened  by  putting  salt  or  alum 
in  the  water,  but  this  makes  the  plaster  somewhat  more  brittle.  After 
the  plaster  is  hard  or  nearly  hard,  the  patient  is  to  be  placed  on  a  soft 
flat  surface,  care  being  taken  not  to  crack  the  plaster  in  so  doing.  The 
edges  of  the  jacket  are  smoothed  down  and  cut  off  if  they  press  un- 
comfortably on  the  thighs  or  axillae. 

It  is  important  that  the  jacket  should  be  strong  in  front  as  well  as 
behind,  and  should  be  wound  as  high  as  possible  in  front,  in   order  to 

'A.  Thorndike :  "Comparison  of  Different  Methods."  Am.  Journ.  Ortli. 
Surg.,  vol.  ii.,  i. 


6o 


ORTHOPEDIC  SURGERY 


prevent  the  spinal  column  from  falling  forward.  If  the  jacket  becomes 
broken  or  softened,  it  should  be  removed  and  another  applied. 

If  the  disease  is  in  the  cervical  region,  the  plaster  bandages  can  be 
carried  up  around  the  back  of  the  head  and  neck  and  under  the  chin, 
leaving  the  face  and  upper  part  of  the  head  exposed,  and  so  fixation 
and  support  may  be  obtained  in  that  part  of  the  vertebral  column. 
This  method  of  fixation  has  certain  manifest  disadvantages  in  lack  of 
cleanliness,  clumsiness,  and  unsightliness,  but  it  is  thorough  and  fur- 
nishes an  excellent  support  and  is  by  no  means  uncomfortable  for  the 
patient. 

It  is  more  efficient  than  the  head  sling  attached  to  a  bent  rod  ex- 
tending above  the  head  and  incorporated  below  into  the  plaster  jacket — 


Fig. 


-Paper  Jacket.     (Children's  Hospital 
Report.) 


Fig.  6o.— Hammock  Frame  for  the  Applica- 
tion of  Jackets  during  Recumbencv  on  the 
Face.     Readv  for  use. 


the  "  jury  mast "  devised  by  Sayre.  The  required  degree  of  suspension 
varies  with  the  seat  of  the  disease  and  the  firmness  of  the  curve;  but 
complete  suspension  is  rarely  necessar}'  in  ceiwical  and  dorsal  cases,  as 
removal  of  the  superimposed  weight  can  be  accomplished  without  this. 
Application  durixg  Recumbexcv  ox  the  Face. — The  patient  is 
laid  face  dowmvard  with  the  armsaboA'e  the  head  on  a  hammock,  which 
consists  of  a  stout  cloth  a  little  wider  than  the  child,  stretched  over  the 
ends  of  a  rectangular  gas-pipe  frame.  One  end  of  this  cloth  is  attached 
to  the  upper  end  of  the  frame  and  does  not  move.  The  other  end  is 
attached  to  a  movable  bar  connected  with  the  other  end  of  the  frame 
by  a  rope.  By  a  ratchet  this  bar  can  be  pulled  upon  and  the  tension  of 
the  cloth  regulated.     The  hammock  may  be  made  very  tight  or  allowed 


TUBERCULOUS  DISEASE   OE   THE  SPIXE.  6i 

to  sag  to  any  extent.  In  this  way  hyperextension  of  the  spine  may  be 
produced  as  desired. 

The  hammock  cloth  is  cut  along  the  sides  of  the  child's  body  longi- 
tudinally and  the  parts  not  under  the  child's  body  are  drawn  aside  and 
fastened  or  cut  away.  The  plaster  rollers  are  then  applied,  including 
both  child  and  hammock. 

Instead  of  the  stretched  hammock  cloth,  the  patient  may  be  placed 
on  two  pieces  of  stout  webbing  stretched  along  the  length  of  a  rectan- 
gular frame.  These  should  be  placed  sufficiently  near  together  to  sup- 
port the  trunk  without  pressure  upon  the  chest.  Cross  straps  of  web- 
bing are  necessarsat  the  hips  and  shoulders  when  the  jacket  is  applied. 


Fig.  CI. — Method  of  Applying  a  Piaster  Jacket  in  Recumbency,  on  the  Harnmock  Frame. 

The  webbing  straps  are  untied  and  patient  released,  after  which  the}" 
are  pulled  out. 

This  method,  as  has  been  demonstrated  by  Brackett,'  is  serviceable 
for  kmibar  and  low  dorsal  disease,  but  is  not  as  satisfactor}-  in  cases  at- 
tacking the  spinal  column  higher  up,  requiring  close  apposition  of  the 
bandages  in  the  upper  part  of  the  front  of  the  chest. 

This  difficulty  and  the  necessity  of  raising  the  shoulders  and  hyper- 
extending  the  spine  above  the  diseased  region  can  be  met  by  the  use  of 
an  appliance  devised  by  one  of  the  writers"  (Fig.  66). 

The  apparatus  consists  of  an  oblong  gas-pipe  frame  of  the  ordinary- 
pattern.      Fastened  to  this  near  the  middle  and  hinged  so  as  to  be 

■  Trans.  Am.  Orthop.  Assn.,  vol.  viii..  p.  i6o. 

-  Lovett:  American  I^Iedicine.  vol.  iv..  Xo.  lo.  p.  373 


62 


ORTHOPEDIC  SURGERY 


raised  to  any  degree  is  another  section  of  gas-pipe  lying  on  the  frame 
proper  and  of  the  same  shape  and  size  as  the  upper  half  of  the  frame. 
To  this  movable  section  is  fastened  at  right  angles  to  it  and  movable  on 
it  a  gas-pipe  bridge,  rising  about  eighteen  inches  from  the  movable  sec- 
tion. 

The  patient  lies  face  downward  on  two  straps  of  webbing,  lying  one 
over  the  other,  run  from  each  of  the  buckles  at  the  bottom  of  the  frame. 
The  lower  pair  of  these  strips  are  tightly  drawn  and  run  to  the  buckles 


Fig.  62.— Plaster  Jacket.     Front  view. 


Fig.  63.— Plaster  Jacket.     Back  view. 


at  the  end  of  the  movable  section.  The  upper  pair  are  loosely  fast- 
ened to  the  bridge  over  the  movable  section. 

The  patient  should  be  placed  in  such  a  way  that  the  seat  of  disease 
comes  opposite  the  hinge  where  the  movable  piece  is  attached,  and  the 
Jiead  and  pelvic  webbing  supports  are  adjusted  to  their  proper  places. 

The  deformity  must  be  very  heavily  padded  by  thick  felt  pads  placed 
on  each  side  of  it.  The  jacket  is  then  applied  in  the  usual  way  up  to 
and  only  as  far  as  the  level  of  the  apex  of  the  deformity  and  allowed 
to  harden.  After  the  plaster  has  hardened,  a  piece  of  webbing  or 
stout  cotton  bandage  running  from  side  to  side  of  the  main  frame  (not 
attached  to  the  movable  section)  is  passed  over  the  upper  back  edge  of 


TUBERCULOUS  DISEASE   OE   THE  SPINE.  63 

the  jacket  and  when  this  is  fastened  in  place  the  movable  section  of 
the  frame  is  lifted  until  the  desired  correction  is  obtained  at  the  seat  of 
the  deformity.  When  the  desired  point  is  reached  the  movable  sec- 
tion is  fastened  in  position  and  a  few  turns  made  with  a  plaster  band- 
age, going  up  two  or  three  inches  above  the  deformity.  Then  the 
straps  running  to  the  end  of  the  movable  section  which  have  been  the 
chief  hyperextending  force  are  unbuckled  and  turned  up  over  the 
bridge,  and  the  patient  remains  suspended  by  the  straps  running  from 


Fig. 


Fig.  64.— Plaster  Jacket.     Side  view. 


—  Plaster  Jacket  and  Head- 
piece.    (WuUstein.) 


the  bottom  of  the  frame  to  the  bridge.  These  are  closely  applied  to 
the  front  of  the  chest  and  shoulders  and  permit  the  upper  part  of  the 
jacket  to  be  firmly  applied  around  the  sternum,  upper  ribs,  and  front  of 
the  shoulders,  holding  the  chest  well  back. 

When  the  plaster  has  hardened  the  webbing  strips  are  unbuckled 
and  the  patient  is  removed  from  the  frame.  The  webbing  strips  are 
easily  pulled  out  from  under  the  jacket  and  are  used  again. 

If  it  is  desirable  to  diminish  lumbar  lordosis,  the  thighs  should  be 
flexed  on  the  body  as  the  patient  lies  on  the  face. 

Application  of  a  Jacket  with  the  Patient  Placed  upon  the 
Back. — In  applying  a  jacket  with  the  patient  lying  upon  the  face  some 


64 


OR  THOPEDIC  S  UR  GER  Y. 


compression  of  the  chest  and  flattening  of  the  abdomen  take  place. 
To  avoid  this,  a  jacket  can  be  appHed  with  the  patient  placed  upon 
his  back.  If  this  were  done  with  the  patient  lying  upon  a  stretched 
sheet,  the  sagging  of  the  material  would  prevent  the  necessary  hyper- 
extension  of  the  spine. 

To  obviate  this,  an  appliance  devised  by  Metzger  and  modified  by 
Goldthwait,  Brackett,  and  R.  T.  Taylor,  will  be  found  of  assistance. 


Fig.  66. — Franite  -with  Movable  Section  for  Application  of  Plaster  Jackets. 

An  upright  steel  rod  is  arranged  with  a  forked  top  on  which  can  be 
placed  two  attachable  pad  plates.  The  rod  fits  in  a  stand  and  can  be 
raised  or  lowered  by  means  of  a  screw.     If  the  patient  is  made  to  lie  in 


Fig.  67. — Frame  with  Movable  Piece  in  Use. 

such  a  way  that,  while  the  head,  shoulders,  and  pelvis  are  supported 
the  kyphus  rests  upon  the  pad  plates,  a  hyperextending  force  is  exerted 
on  the  kyphus.  As  the  rod  bearing  the  pad  plates  is  raised  or  lowered, 
the  pressure  on  the  kyphus  is  increased  or  diminished.  Any  desired 
amount  of  hyperextension  of  the  spine  can  be  furnished. 

Exaggerated  lordosis  can  be  prevented  by  flexing  the  thighs. 

Brackett  has  attached  the  upright  rod  to  a  frame,  such  as  is  used  in 
the  hammock  application  of  jackets. 


TUBERCULOUS  DISEASE   OF    THE  SPINE. 


65 


Goldthvvait '  and  R.  T.  Taylor  have  employed  the  principle  by 
means  of  two  movable  stands,  the  former  employing  two  parallel  steel 
rods  connecting  the  uprights  as  a  support  to  the  lower  part  of  the  back, 
which  are  removed  after  the  jacket  has  hardened. 

R.  T.  Taylor  *  has  combined  the  arrangement  with  a  mechanism  for 


Fli5.  6S. — Frame  for  Applying  Jaclcet  with  Patient  Recumbent  upon  the  Back.       (Metzg^er- 

Goldthwait.) 

a  pull  and  a  counter-pull.  The  jacket  is  applied  in  the  usual  way  and 
the  patient  placed  in  the  desired  position. 

Jackets  Applied  with  the  Patient  Sitting. — The  patient  may 
be  seated  during  the  application  of  the  jacket  if  it  is  desired  to  prevent 
lordosis  in  the  lumbar  region. 

In  disease  of  the  lumbar  region,  since  lordosis  is  desirable  to  sepa- 


FlG.  69.— Portable  Frame  for  Applying-  Plaster  Jacket.     (Metzger-Goldthwait.) 

rate  the  lumbar  vertebree,  suspension  is  not  necessary.  The  jacket  can 
be  applied  with  the  patient  steadied  and  the  back  arched  forward  to 
secure  exaggerated  lordosis. 

R.  T.  Taylor '  has  applied  jackets  for  disease  of  the  spine  with  the 
patient  seated,  using  an  arrangement  which  can  be  readily  understood 
by  the  accompanying  illustration  (Fig.  70). 

In  adult  cases  of  caries  of  the  spine  in  the  upper  dorsal  or  cervical 
regions  with  slight  kyphus,  jackets  can  be  applied  with  the  patients 
seated,  with  the  slight  correction  afforded  by  head-sling  traction. 

^  Trans.  Am.  Orth.  Assn.,  xi.,  89. 
•Johns  Hopkins  Bulletin,  xii..  119. 
Johns   Hopkins  Bulletin,  February.  1S95,  No.  45.     Trans.  Am.  Orth.  Assn  , 
vol.  -xii.,  p.  119. 

5 


66 


ORTHOPEDIC  SURGERY. 


It  is  desirable  that  tlie  surgeon  should  familiarize  himself  with  the 
application  of  plaster  jackets  by  the  different  methods  mentioned,  as  it 
will  be  found  that  they  are  of  assistance  in  different  cases.  Frightened 
children  are  less  alarmed  if  placed  upon  a  hammock  than  if  suspended. 
A  jacket  applied  with  the  patient  placed  upon  a  hammock  is  useful  in 
low  dorsal  caries,  but  is  less  satisfactory  in  mid  or  upper  dorsal  caries. 
By  the  aid  of  the  correcting  appliance  an  efficient  jacket  can  be  applied 
in  upper  dorsal  caries  with  the  patient  prone.  A  jacket  where  espe- 
cial attention  is  needed  in  front  is  thus  readily  applied  with  the  patient 
lying  upon  the  face.  Where  hyperextension  is  needed  it  can  be  ac- 
complished best  by  means  of  the  apparatus  described  for  application 
of  the  jacket  in  back  recumbency.  The  seated  position  is  most  con- 
venient for  the  patient ;  for  simple  cases  with  slight  deformity,  where 
much  hyperextension  is  not  needed  and  where  the  head  is  to  be  in- 
cluded in  the  jacket,  suspension  with  the  patient  upright  will  be  found 
the  most  satisfactory  method. 

It  is  sometimes  the  case  that  a  jacket  may  be  applied  which  appar- 


FlG.  70. — Child  in  Recumbent  Kyphotone  Ready  for  Application  of  Jacket.      (R.  T.  Taylor.) 


ently  is  furnishing  satisfactory  support,  while  the  surgeon  may  wish  to 
determine  the  exact  amount  and  seat  of  efficient  pressure.  A  simple 
method  of  determining  this,  without  injury  to  the  jacket,  has  been  em- 
ployed by  Dr.  A.  Thorndike.  A  narrow  longitudinal  slit  is  cut  for  a 
sufficient  distance  in  the  back  of  the  jacket,  which  is  made  thick  for 
the  purpose,  and  the  position  of  the  spine  held  in  the, jacket  determined 
by  taking  a  tracing  of  the  spinous  processes  through  the  slit.' 

The  most  acceptable  form  of  permanent  jacket  is  one  applied  over  a 
seamless  woven  shirt.  These  shirts  are  made  very  long  and  reach  the 
knees ;  one  of  them  is  put  on  the  patient  and  the  jacket  applied  over 
it.  The  lower  part  of  the  shirt  is  then  turned  up  over  the  outside  of 
the  jacket  and  reaches  to  the  top  of  it.  It  is  there  stitched  to  the  up- 
per part  of  the  shirt  along  the  upper  edge  of  the  jacket.  This,  how- 
'  Am.  Journ.  of  Orth.  Surgery,  ii..  2. 


TUBERCULOUS  DISEASE   OF   THE  SPINE.  6/ 

ever,  is  not  done  until  the  jacket  has  been  removed,  by  splitting  it 
down  the  front  and  gently  springing  it  open.  The  edges  of  the  cut  are 
stitched  with  leather  and  a  row  of  hooks  is  provided  on  each  side 
with  which  to  lace  it  together.  A  jacket  is  thus  provided,  which  is 
covered  inside  and  outside  with  soft  woollen  material,  which  can  be 
removed  for  purposes  of  cleanliness  and  reapplied  to  the  patient, 
who  should  be,  of  course,  suspended  or  laid  on  the  face  for  each  reap- 
plication. 

Removable  Jackets. — After  a  jacket  has  been  applied  by  any  one 
of  these  methods,  it  may  be  converted  into  a  removable  jacket.  Re- 
movable jackets  are  not,  however,  such  efficient  supports  as  fixed  jack- 
ets during  the  acute  stage  of  the  disease.  They  are,  as  a  rule,  to  be 
used  in  convalescent  cases,  in  exceptional  cases  in  the  acute  stage  when 
the  skin  is  very  sensitive  and  requires  bathing,  when  sloughs  or  excori- 
ations are  present,  and  in  similar  conditions. 

As  a  substitute  for  plaster  jackets,  corsets  are  made  of  leather 
(Chapter  XXL,  3),  felt,  wood,  aluminum,  celluloid  (Chapter  XXL,  2), 
papier-mache,  silicate  of  potash,  etc.  The  plaster  jacket,  which  is  ap- 
plied in  the  usual  way,  is  removed  with  care  so  as  to  preserve  its  shape. 
A  cast  of  plaster  of  Paris  is  taken  from  the  jacket,  and  on  this  as  a 
form  a  corset  is  made  of  leather  (which  when  wet  can  be  stretched 
tightly  over  the  form).  After  the  plaster  jacket  has  become  hard,  it 
can  be  split  and  furnished  with  eyelets  and  lacings ;  it  can  then  be  ap- 
plied on  the  patient,  who  is  suspended,  as  in  the  application  of  a  plas- 
ter jacket.  Rawhide  stretched  over  a  cast,  thoroughly  dried  and  left 
until  hardened,  furnishes  a  corset  which  is  both  light  and  firm.  The 
process  of  manufacture  requires  attention  and  detail.  The  same  is 
true  of  a  jacket  made  of  celluloid.  Both  of  these  corsets  curl  unless 
equally  dried,  before  using,  on  the  inner  and  outer  side. 

In  the  upper  dorsal  and  cervical  region  it  is  necessary  either  to  add 
to  the  plaster  jacket  an  appliance  for  securing  the  head  (the  varieties 
of  which  will  be  mentioned  later),  or  to  carry  the  plaster  jacket  over 
the  shoulders  and  neck.  A  plaster  collar  applied  simply  to  the  neck, 
and  not  to  the  trunk,  does  not  give  sufficient  support  except  in  disease 
of  the  upper  cer\'ical  vertebrae. 

They//;j  mast  consists  of  a  bent  rod  of  steel  running  up  from  the 
jacket,  following  the  curve  of  the  neck  and  head  to  a  point  above  the 
top  of  the  head.  To  the  end  of  this  rod  is  attached  a  cross  bar  which 
carries  a  head  sling.  The  lower  end  of  the  jury  mast  terminates  in  a 
metal  framework,  which  is  incorporated  in  the  jacket.  By  raising  the 
head  sling  the  head  can  be  pulled  upward.  But  it  is  very  difficult  in 
practice  to  keep  up  continuous  traction  on  the  head  in  this  wav,  and 
the  inconvenience  and  unsightliness  of  the  apparatus  are  objectionable. 

The  chief  objection  to  the  treatment  of  Pott's  disease  with  a  perma- 


68 


ORTHOPEDIC  SURGERY. 


nent  plaster  jacket  is  in  the  uncleanliness.  Removable  jackets  and  cor- 
sets are  not  firm.  As  a  base  for  head  supports  in  the  upper  dorsal  and 
cervical  regions  a  corset  is  not  readily  applied  and  is  more  unsightl}- 
than  a  well-fitted  appliance ;  but  in  the  mid-dorsal  and  upper  lumbar 
region  the  permanent  plaster  jacket  must  be  regarded  as  the  most  effi- 
cient ambulatory  fixative  appliance. 

When  a  lateral  deviation  of  the  spinal  column  is  present  with  Pott's 

disease,  the  jacket  is  preferable  to 
any  brace. 

In  disease  which  is  very  low 
down,  the  jacket  is  often  a  more 
efficient  and  comfortable  mode  of 
treatment.  For  careless  and  igno- 
rant patients  a  jacket  which  is  not 
removable  is  far  preferable  to  any 
apparatus  which  they  can  misuse. 
Moreover,  the  cheapness  of  the 
jacket  brings  it  within  reach  of 
many  people  who  would  otherwise 
have  to  go  without  treatment. 


Fig.  71. — Antero-Posterior   Support   Ap- 
plied.    (Dr.  H.  L.  Taylor.) 


Fig.  72.— Taylor's  Chest  Piece. 


As  to  the  method  of  application  of  a  jacket,  it  is  to  be  remembered 
that  the  object  is  to  secure  fixation  of  the  spine  in  an  improved  posi- 
tion. As  much  force  should  be  used  as  will  secure  this  without  caus- 
ing undesirable  traumatism  at  the  seat  of  the  disease.  Suspension 
alone  is  the  least  efficient  of  all  means.  Recumbency  on  the  hammock, 
the  kyphotone  of  Taylor,  and  the  two  frames  mentioned  (all  of  which 
induce  an  improved  position  by  the  local  use  of  force)  are  the  most  effi- 
cient. It  is  desirable  in  severe  cases  to  carry  the  jacket  over  the 
shoulders  and  to  have  the  jackets  durable  enough  to  be  worn  for 
months.  They  should  be  changed  with  every  care  not  to  increase  the 
deformity  in  the  process,  even  temporarily.     The  method  to  be  chosen 


TUBERCULOUS  DISEASE   OF   THE  SPTXE. 


69 


will  vary  largely  with  the  familiarity  of  the  surgeon  with  that  especial 
method.  No  one  of  the  methods  mentioned  as  efficient  is  to  be  advo- 
cated to  the  detriment  of  the  other  methods  similarly  classed. 

Tre.vtment  bv  Steel  Appliances. 

The  basis  of  ambulatory  treatment  of  Pott's  disease  in  the  subacute 
or  convalescent  stage  is  fi.xation,  as  complete  as  possible,  of  the  spine 


Fig.  73.— Antero-Posterior  Brace  for  Dorsal  Pott's 
Disease  Applied. 


Fig.  74. — Antero-Posterior  Brace  for 
Pott's  Disease ;  showing  Apron 
and  Leather  Gorget. 


in  as  advantageous  a  position  as  obtainable.  This  may  be  done  by 
means  of  a  properly  made  appliance. 

As  the  chief  motion  of  the  spine  to  be  guarded  against  is  the  for- 
ward motion,  the  principle  of  the  appliance  is  that  of  an  antero-poste- 
rior  support.  This  was  first  efficiently  applied  by  Dr.  C.  F.  Taylor,  of 
Xew  York,  as  a  method  of  thorough  treatment,  as  it  involves  skill  and 
anatomical  and  pathological  knowledge. 

The  construction  and  application  of  a  brace  should  be  superintended 


70 


ORTHOPEDIC  SURGERY. 


directly  by  the  surgeon,  and  not  relegated  to  an  instrument-maker. 
The  details  relative  to  the  future  result  are  fully  as  important  as  the 
application  of  a  splint  in  any  fracture,  for  the  result  will,  in  a  great 
measure,  depend  on  the  accuracy  of  adjustment.  For  the  construction 
of  a  splint  a  cardboard  tracing  of  the  back  should  be  made  at  one  side 
of  the  spinous  processes. 

The  simplest  antero-posterior  apparatus  (Chapter  XXI.,  4)  consists 
of  two  uprights  of  annealed  steel.  The  uprights  are  joined  together 
below  by  an  inverted  U-shaped  piece  of  steel  which  runs  as  far  down 
on  the  buttock  as  possible  without  reaching  the  chair  or  bench  when 


73     74    77    1864 


Fig.  7i.— Tracings  showing  Results  of  Brace  Treatment  as  Carried  Out  by  Dr.  C.  F.  Taylor. 
/,  Two  and  three-quarters  years,  first  and  second  lumbar  disease,  five  3-ears'  treatment ; 
//,  eight  years,  eleventh  and  twelfth  dorsal,  four  years'  treatment ;  ///,  four  j^ears,  first 
lumbar,  ten  years'  treatment  ;  /F,  three  and  one-half  years,  six  years'  treatment ;  V.  five 
years,  twelfth  dorsal,  first  and  second  lumbar,  nine  years'  treatment  ;  VI,  five  and  one- 
half  vears,  sixth  and  eighth  dorsal,  four  years'  treatment  ;  VII,  about  eighteen,  dorso- 
lumbar,  eight  years'  treatment  ;  VIII,  nine  years,  seventh  to  ninth  dorsal,  seven  years' 
treatment;  IX,  twenty  years,  five  years'  treatment;  X,  ten  years,  eight  years'  treat- 
ment. (Dates  are  given  with  tracings  ;  the  age  given  is  that  at  which  treatment  was  be- 
gun.) 

the  patient  sits  down.  Or  the  brace  may  end  in  a  waistband.  At  the 
top  the  uprights  end  in  shoulder  pieces  running  over  the  shoulders. 

The  brace,  after  being  put  together  but  before  being  finished, 
should  be  tried  on  the  patient,  who  should  be  lying  on  his  face.  Any 
alteration  necessary  in  the  curves  of  the  steel,  in  order  to  have  the  ap- 
pliance fit  closely  to  the  back  along  its  whole  length,  can  be  made  with 
wrenches.  The  brace  can  be  faced  with  hard  rubber  or  covered 
smoothly  with  leather.  An  accurate  fit  is  essential ;  the  covering  is 
merely  a  matter  of  detail. 

Accurately  fitting  pad  plates  covered  with  felt  and  leather  or  hard 
rubber  are  needed.  In  some  instances,  at  the  points  of  greatest  press- 
ure, the  bars  of  the  brace,  if  well  padded,  answer  every  purpose. 
33uckles  are  needed  at  various  levels. 


TUBERCULOUS  DISEASE   OE   THE  SPINE. 


71 


If  properly  designed  the  appliance  will  press  firmly  at  the  deformity, 
i.e.,  the  pad  plates  and  pressure  should  be  uniform  at  this  point  and 
closely  fitted  to  the  contour  of  the  deformity  in  all  planes.  The  appli- 
ance will  also  touch  necessarily  at  the  top  and  bottom,  but  the  chief 
pressure  should  be  at  the  kyphus.  Variations  from  this  type  of  con- 
struction will  naturally  be  of  use.  Nicety  of  workmanship  in  the  man- 
ufacture of  a  brace  is  of  relatively  secondary  importance.     The  essen- 


lOmos 


3  years 


17mos 


Umos 


9         10 


11  12 


omos  9mos 

Fig.  75(7. — Results  of  Hj-perextension  Treatment  (Goldthwait).  i,  At  beginning  of  treatment  ; 
2,  ten  months  later  ;  3,  at  beginning  of  treatment  ;  4,  same,  three  years  later  ;  5,  at  begin- 
ning of  treatment ;  6,  seventeen  months  later  ;  7,  at  beginning  of  treatment  ;  8,  seventeen 
months  later  ;  9,  at  beginning  of  treatment  ;  10,  same,  five  months  later  ;  11,  at  beginning 
of  treatment  ;  12,  same,  after  nine  months. 

tial  is  that  it  should  be  mechanically  efficient  in  meeting  the  indications 
of  fixation.  The  construction  of  the  brace  does  not  necessarily  involve 
expensive  workmanship,  and  need  not  be  anything  beyond  the  skill  of  a 
village  blacksmith.  It  should  be  borne  in  mind  that,  besides  accuracy 
of  fit  and  proper  design,  it  is  of  importance  that  the  apparatus  be  stiff 
enough  not  to  yield  as  the  weight  of  the  trunk  falls  upon  it,  inasmuch 
as  yielding  involves  intervertebral  pressure.  This  is  true  not  only  of 
the  uprights,  but  also  of  the  band.  A  stiff  appliance,  if  properly  fitted, 
can  be  made  as  comfortable  as  a  yielding  one,  and  is  much  more  efficient. 


72  ORTHOPEDIC  SURGERY. 

An  error  in  accuracy  of  fit  may  be  sufficient  to  furnish  insufficient 
protection  and  cause  relapse.  Moreover,  it  is  necessary  that  the  patient 
should  be  seen  often  enough  to  keep  the  brace  fitting  accurately,  for 
the  deformity  may  increase  or  diminish  at  any  time.  In  such  a  case 
the  brace  becomes  inefficient. 

It  is,  of  course,  essential  that  the  trunk  be  properly  secured  to  the 
brace.  This  can  be  done  in  part  b}-  means  of  an  apron,  which  covers 
the  front  of  the  trunk,  the  abdomen,  and  the  chest,  reaching  from  the 
clavicles  nearly  to  the  symph3'sis  pubis.  The  apron  is  provided  with 
webbing  (non-elastic)  straps,  which  are  fastened  into  buckles  attached 
to  the  brace.  Padded  straps,  passing  from  the  top  of  the  brace  around 
the  arms,  under  the  axillae,  and  attached  to  buckles  in  the  middle  of  the 
brace,  help  to  secure  it ;  but  the  scapulas,  being  movable,  cannot  be  re- 
lied upon  alone  to  fix  the  trunk,  and  the  apron  must  be  furnished  with 
straps  at  the  top,  which  pass  over  the  shoulders  to  buckles  in  the  top 
of  the  brace. 

In  adults  it  is  often  convenient  to  have  the  apron  split  dowm  the 
front  and  proxided  with  webbing  straps  and  buckles,  so  that  the  patient 
can  adjust  it  himself  by  tighening  the  straps  in  front. 

To  secure  a  proper  hold  upon  the  upper  segment  of  the  body  in 
dorsal  disease  some  unyielding  and  rigid  chest  piece  is  necessary. 
Taylor's  chest  piece  acts  by  means  of  hard-rubber  pads  at  the  upper 
part  of  the  chest,  connected  by  a  steel  rod,  which  keeps  the  brace 
closely  against  the  back.  The  pads  of  the  chest  piece  may  be  made  of 
hard  rubber  and  fit  in  below  the  clavicles,  where  they  cause  no  discom- 
fort and  restrict  the  chest  movements  less  than  the  apron,  besides 
affording,  more  definite  support.  Other  forms  of  chest  piece  are  in 
use.  A  simple  one  can  be  made  over  a  plaster  cast  of  the  chest  by 
shaping  leather  which  is  afterward  stiffened  by  treatment  with  hot  wax. 
This  may  be  extended  upward  to  support  the  chin  in  cases  of  high  dor- 
sal disease.     To  this  hard  leather,  steel  buckles  may  be  attached. 

The  brace  should  be  w'om  day  and  night,  and  removed  daily  that 
the  back  may  be  bathed.  While  the  brace  is  off,  the  patient  should  lie 
on  the  face  or  the  back.  On  no  account  should  he  sit  erect.  The 
back,  after  being  washed,  should  be  rubbed  with  alcohol  and  then  pow- 
dered with  face  powder,  corn  starch,  or  Pears'  fuller's  earth.  The 
brace  should  then  be  applied  and  buckled  tightly  into  place. 

Chafing  of  the  back  is  sometimes  unavoidable  in  summer.  When  a 
severe  chafed  spot  forms,  the  brace  must  be  removed  for  the  time  and 
the  child  should  lie  flat  in  bed  until  the  ulcer  heals.  A  smooth  cover- 
ing of  leather  is  least  irritating  to  the  skin.  The  brace  may  be  worn 
over  a  cloth  or  undervest,  but  is  least  likely  to  chafe  if  applied  directly 
over  the  skin. 

Dr.  Judson  formulates  a  general  rule  which  may  serve  as  a  guide  in 


TUBERCULOUS  DISEASE   OF    THE  SPINE. 


/  0 


the  treatment  of  Pott's  disease  by  rigid  apparatus,  especially  in  all 
forms  of  the  antero-posterior  support.  The  rule  reads:  "The  appara- 
tus may  be  considered  as  having  reached  the  limit  of  its  efificiency  if  it 
makes  the  greatest  possible  pressure  on  the  projection  compatible  with 
the  comfort  and  integrity  of  the  skin." 

Certain  braces  have  a  tendency  to  "ride-up,"  and  the  neck  pieces, 
instead  of  lying  closely  to  the  shoulders,  project  upward  in  a  most  un- 
sightly way.     In  general,  this  does  not  occur  in  braces  which  fit  accu- 


<^' 


/ 


Fig.  76.— Taylor  Back  Brace  with  Oval 
Ring.     Head  support  applied. 


Fig.  77.— Antero-Posterior  Brace  with    Bent 
Wire  Head  Support. 


rately.  Sometimes,  however,  it  is  most  troublesome,  and  in  these 
cases  padded  perineal  straps  can  be  added,  which  are  attached  to  the 
apron  in  front  and  to  the  lower  end  of  the  brace  behind.  They  are, 
however,  a  source  of  much  annoyance  to  children,  in  urination  espe- 
cially, and  are  to  be  avoided  if  possible.  The  apron  will  sometimes  be 
found  to  cut  over  the  anterior  superior  spines  of  the  ilium  and  also 
under  the  arms,  and  must  be  properly  padded. 

In  applying  the  brace  the  patient  should  lie  upon  his  face,  and  the 
apron  be  spread  under  him.     The  brace  should  then  be  placed  in  posi- 


74  ORTHOPEDIC  SURGERY. 

tion  upon  the  bare  back,  or  upon  a  thin,  smooth  cloth  without  wrinkles, 
and  the  apron  strapped  to  it  as  tightly  as  is  possible.  The  more  tightly 
the  two  are  strapped  together,  the  more  thorough  is  the  fixation.  The 
position  of  the  straps  and  their  number  will  vary  in  cases  according  to 
the  situation  of  the  disease,  etc.  The  brace  must,  of  course,  if  it  is  to 
exert  pressure,  always  be  straighter  than  the  spine. 

A  troublesome  complication  in  the  use  of  the  antero-posterior 
brace  is  the  presence  of  a  lateral  curve  in  the  vertebral  column ;  this 
has  been  mentioned  as  an  occasional  complication  of  Pott's  disease. 
The  brace  fits  when  the  child  lies  down,  but  when  he  sits  up  the  col- 
umn leans  to  one  side  again,  and  it  is  of  course  impossible  for  the  brace 
to  fit  as  before.  Fortunately,  this  symptom  passes  slowly  away  as  effi- 
cient support  is  afforded  to  the  column,  and  then  the  brace  fits  again. 
Meantime  it  is  best  to  apply  the  brace,  bending  up  one  neckpiece  and 
bending  the  other  down  to  make  the  top  of  the  brace  set  squarely,  or  to 
apply  a  plaster  jacket,  which  is  ordinarily  the  most  available  mode  of 
treatment  under  these  conditions ;  it  is  also  best  to  keep  the  patient 
in  a  recumbent  position  as  much  as  possible  until  the  deformity  im- 
proves. 

The  application  of  the  therapeutic  principle  of  fixation  in  the  best 
possible  position  varies  according  as  the  disease  involves  the  upper, 
middle,  or  lower  parts  of  the  spinal  column. 

Head  Supports. — In  the  upper  region,  as  elsewhere,  it  is  desirable 
to  prevent  the  weight  of  the  head  from  falling  upon  the  diseased  bodies 
of  the  vertebrae. 

An  efficient  arrangement  is  one  devised  by  Dr.  Taylor,  of  New 
York  (Chapter  XXI.,  5) ;  an  ovoid  steel  ring  passes  around  the  neck, 
made  so  that  it  can  open,  and  be  secured  when  closed,  and  arranged  so 
that  it  can  serve  as  a  rest  for  the  chin,  and  so  that  pressure  can  also  be 
exerted  on  the  occiput.  This  collar  has  at  the  front  a  hard-rubber  chin 
piece  accurately  shaped  to  the  chin,  and  may  have  at  the  back  a  stiff 
piece  of  sole  leather  projecting  up  from  the  back  of  the  ring.  This 
steadies  the  head  and  prevents  the  pressure  of  the  occiput  against  the 
back  of  the  headpiece.  This  collar  at  the  back  plays  on  a  pivot,  allow- 
ing lateral  motion  of  the  head.  The  pivot  is  attached  to  the  usual  back 
brace,  and  can  be  raised  or  lowered,  as  it  is  desired  to  increase  or  di- 
minish the  upward  pressure  on  the  head.  This  appliance  requires  care 
and  skill  in  application,  and  is  useless  unless  properly  fitted. 

Other  forms  of  head  support  have  been  tried  from  time  to  time. 
Some  of  them  have  been  useful  (Chapter  XXI.,  6). 

A  head  support,  devised  by  Goldthwait,  affords  good  fixation.  Its 
construction  is  evident  from  the  figure,  and  it  is  serviceable  in  cases  in 
which  there  is  excessive  sensitiveness  of  the  spine,  due  to  cervical  or 
very  high  dorsal  disease.     The  quadrilateral  back  brace  devised  by 


TUBERCULOUS  DISEASE   OF   THE  SPINE. 


75 


Dane  ^  furnishes  a  useful  form  of  support  in  Pott's  disease  (Chapter 
XXI.,  8). 

Collars  of  various  sorts,  unattached  to  any  other  appliance,  have 
been  used,  which,  pressing  on  the  chin  and  occiput  above,  and  on  the 
clavicles,  sternum,  and  shoulders  below,  transfer  the  weight  in  part 
from  the  intermediate  cervical  vertebrse  and  check  the  forward  bending 
of  the  cervical  region.  These  collars  can  be  made  of  plaster  of  Paris, 
but  are  cumbersome  and  unsightly.  The  most  easily  made  collar  is 
that  invented  by  the  late  H. 
O.  Thomas,  of  Liverpool 
(Chapter  XXI.,  7).  Leather 
stuffed  with  sawdust  is  the 
most  available  material  of 
which  to  make  them.  They 
may  also  be  made  of  tin, 
silicate  of  potash,  wire  net- 
ting, cardboard   doubled   and 


Fig.  yS.— Thomas  Leather  Collar. 


Fig.  79.— Leather  Jacket  with  Head  Support. 


of 


padded,   or   any   of    the    other   materials   mentioned   in   speakin 
corsets. 

A  convenient  way  of  making  these  collars  is  by  taking  a  piece  of 
stout  webbing,  long  enough  to  go  loosely  around  the  neck,  and  wind- 
ing it  with  sheet  wadding  or  oakum  until  it  is  padded  sufficiently. 
Then  it  should  be  covered  with  a  bandage  outside,  and  the  ends  of  the 
webbing  should  be  buckled  together.  The  patient  wears  the  collar  a 
few  days,  and  then  as  the  padding  becomes  matted  down,  new  padding 
'  Pediatrics,  vol.  x.,  i..  1900. 


ORTHOPEDIC  SURGERY. 


is  added  until  the  collar  is  the  desired  size  and  shape.  It  is  then  sent 
to  a  harnessmaker  to  be  covered  with  leather.  In  this  way  a  much 
more  satisfactory  result  is  obtained  than  by  sending  measures  to  a  har- 
nessmaker in  the  first  place. 

In  all  forms  of  head  supports,  if  worn  for  a  long  time,  a  certain 
amount  of  recession  of  the  chin  takes  place.  The  nature  of  this  is  not 
clearly  understood,  but  the  growth  of  the  lower  jaw  is  in  a  measure 
temporarily  interfered  with,  and  the  front  teeth  in  the  lower  jaw  in 
severe  cases  do  not  articulate  with  those  of  the  upper.  The  distortion 
results  from   the  continued  use  of  any  form  of  head  support,  and  is 

more  lial^le  to  occur  the  more 
efficient  the  support.  The  jaw 
gradually  resumes  its  shape 
after  removal  oi  the  head  sup- 
port. 

Collars,  however,  lack  in 
steadiness,  and,  in  order  to  se- 
cure accurate  fixation  of  the 
head,  they  should  be  connected 
with  uprights  which  extend  be- 
low and  are  attached  to  the 
trunk.  The}-  are  adapted  only 
to  the  treatment  of  cervical  dis- 
ease of  a  character  not  very 
acute.  \Mien  torticollis  is  pres- 
ent as  the  result  of  irritation, 
treatment  b}'  recumbency  is 
advisable. 

It  is  hard  to  say  just  when 
the  need  for  a  head  support  be- 
gins. In  general,  if  the  disease 
is  above  the  sixth  dorsal  verte- 
iDra,  a  headpiece  is  indicated.  Sometimes,  if  the  disease  is  lower  down, 
pain  or  distortion  makes  it  evident  that  a  head  support  is  needed  there 
also,  or  it  may  be  necessary  to  add  one  if  the  brace  does  not  make  satis- 
factory pressure  at  the  seat  of  deformitw 


"IG.  80. — Collar  and  Chest  Piece  for  Cervical  Pott" 
Disease. 


Selection  of  .\  Method  of  Treatment. 

In  the  selection  of  mechanical  supports  the  choice  will  lie  between 
some  of  the  fixed  corsets  of  plaster  of  Paris  (or  the  variations  of  that 
form  of  corset  fixation)  and  the  anteroposterior  supports  of  steel. 

When  careful  and  skilled  attention  can  be  applied  to  the  construc- 
tion, attention,  and  needed  alteration  of  a  brace,  it  will  be  found  of 
great  efficiencv  in  the  treatment  of  Pott's  disease  in  the  convalescent 


TUBERCULOUS  DISEASE   OF   THE  SF/AUi. 


/  / 


stage.  It  should  be  remembered,  as  has  been  shown,  that  it  is  impossi- 
ble to  pry  the  vertebrae  apart  by  leverage,  as  no  apparatus  could  be 
worn  which  would  sustain  absolutely  the  weight  of  the  upper  part  of 
the  trunk  from  falling  forward.  The  antero-posterior  support  is  to  be 
regarded  as  an  apparatus  which  modifies  rather  than  relieves  interver- 
tebral pressure  by  the  principle  of  leverage. 

The  chief  objection  to  the  use  of  mechanical  appliances  as  a  method 
of  treatment  is  that  care  and  special  skill  are  required,  not  only  in  the 
application  of  braces,  but  in  the  inspection  and  management  of  the  cases. 

If  the  trunk  is  not  thoroughly  fixed  by  the  straps,  etc.,  of  the  ap- 
pliance, the  brace  becomes  simply  a  splint  of  steel  laid  upon  the  back, 
and  not  a  therapeutic  agent. 

Rectific.\tiox  of  the  Deformity  (Forcible  Correction). 

P^orcible  correction  of  the  deformity,  with  or  without  anaesthesia,  is 
a  method  revi\-ed  in  recent  times  by  Chipault,  of  Paris,  although  ordina- 


FlG.  Si. 


-Pott's  Disease  before  Correction. 
(Goldthwait.) 


Fig.  82.  — Satne  Case  Twelve  Weeks  after  Cor- 
rection.    (Goldthwait.) 


rily  identified  with  the  name  of  Calot,  of  Berck-sur-Mer.  The  latter 
demonstrated  that  under  an  anaesthetic  a  recent  deformity,  even  of 
large  size,  may  be  partially  or  wholly  corrected.  Although  it  was 
shown  that  this  is  not  a  proceeding  attended  with  as  great  risk  to  life, 
either  near  or  remote,  as  would  have  been  supposed,  many  casualties  of 
various  sorts  have  been  reported. 


78  ORTHOPEDIC  SURGERY. 

Hemorrhage,  rupture  of  the  pleura,  rupture  of  abscesses,  and  frac- 
ture of  the  spine  as  well  as  paralyses  are  among  the  results  reported, 
following  injudicious  application  of  the  method. 

In  6io  cases'  reported  by  various  operators,  21  deaths  occurred, 
which  is  sufficient  evidence  against  the  employment  of  great  force. 

It  is  obvious  from  the  inspection  of  any  series  of  pathological  speci- 
mens of  cured  cases  of  Pott's  disease  that  the  diseased  tissue  is  replaced 
by  sound  bony  tissue  to  hold  the  disabled  column,  if  time  enough  is 
given  and  if  the  process  of  repair  has  not  been  overwhelmed  by  the 
process  of  destruction.  Where  much  force  is  needed  to  correct  the 
deformity,  the  products  of  cicatrization  will  be  torn  or  injured  in  the 
procedure.     This,  if  extensive,  is  manifestly  to  be  avoided. 

But  although  the  correction  of  deformit}^  by  the  use  of  violence  is 
irrational  and  may  be  seriously  injurious,  the  employment  of  moderate 
force  in  correction  is  frequently  beneficial.  When  ankylosis  and  cica- 
tricial changes  have  taken  place  in  the  shape  of  the  vertebral  bodies, 
the  surgical  indications  are  to  be  content  with  the  established  cure, 
without  incurring  the  risk  of  kindling  the  tuberculous  ostitis  b}'  violence. 
In  the  majority  of  recent  cases,  especially  in  children,  this  condition  of 
cicatrization  has  not  been  reached,  as  years  are  usually  necessary  before 
a  cure  is  accomplished,  and  in  these  the  kyphosis  can  generally  be  made 
straighter  by  the  use  of  comparatively  moderate  force  without  the  need 
of  an  anaesthetic. 

The  mechanical  means  for  rectification  are  those  already  mentioned 
as  of  use  in  the  application  of  plaster  jackets.  Rectification  judiciously 
applied  is  beneficial  in  all  active  cases  of  Pott's  disease.  Pressure 
symptoms  will  be  relieved  and  in  some  instances  paralysis  checked. 

In  older  cicatrized  cases  great  judgment  is  necessary  in  the  employ- 
ment of  correcting  force. 

It  must  also  be  understood  that  after  correction  a  relapse  of  the 
curve  will  take  place  unless  the  corrected  position  is  maintained  by 
adequate  fixed  appliances  until  the  spine  is  well  cicatrized  in  the  cor- 
rected position. 

Operations  ox  the  Diseased  Vertebra. 

Operative  measures  are  necessary  under  exceptional  circumstances 
for  the  direct  examination  of  the  diseased  vertebral  bodies  and  the  re- 
tnoval  or  drainage  of  the  diseased  bone.  It  must  be  remembered  that 
in  any  event  the  vertebral  bodies  are  more  or  less  inaccessible,  and  that 
such  operations  are  not  likely  to  prove  of  benefit  as  routine  measures. 

In  the  cervical  region  the  anterior  surfaces  of  the  bodies  of  the  ver- 

'E.  H.  Bradford  and  Vose,  giving  bibliography:  Trans.  Am.  Surgical  Assn., 
1S99  —Bradford  and  Cotton:  Boston  Med.  and  Surgical  Journal,  September  20th, 
I  goo. 


TUBERCULOUS  DISEASE   OF   THE  SPINE.  79 

tebrae  may  be  reached  either  through  the  mouth,  by  a  lateral  incision, 
or  by  incision  in  the  back  of  the  neck.  Through  the  mouth  the  oper- 
ating space  is  small,  the  proceeding  difficult  on  account  of  the  anaes- 
thetic, and  the  dangers  of  infection  are  evident.  This  method  makes 
accessible  only  the  second,  third,  and  fourth  vertebral  bodies.  The 
lateral  method  is  preferable.  An  incision  is  made  along  the  posterior 
border  of  the  sternomastoid  muscle ;  the  sternomastoid  and  omohyoid 
are  raised  and  the  space  made  by  the  splenius  and  omohyoid  is 
reached.  The  dissection  is  carried  through  the  longus  colli,  and  the 
vertebral  arteries  are  avoided. 

In  the  dorsal  region  exploration  may  be  advisable  in  case  an  abscess 
in  the  posterior  mediastinum  is  suspected.  In  such  cases  the  operation 
of  costo-transversectomy  should  be  done.  An  incision  at  the  side  of  the 
spinous  processes  uncovers  the  tops  of  the  transverse  processes  and  the 
bases  of  the  ribs.  The  ribs  are  divided  at  the  tuberosities  and,  with 
the  transverse  processes,  removed.  The  spine  is  then  reached  by  the 
finger. 

In  the  lumbar  region  an  incision  is  made  from  the  twelfth  rib  to  the 
ilium,  two  and  one-half  inches  outside  of  the  median  line ;  the  incision 
reaches  to  the  border  of  the  quadratus  lumborum  and  the  tips  of  the 
transverse  processes  should  be  felt.  The  dissection  is  carried  down  to 
the  psoas  muscle ;  some  of  the  fibres  of  this  muscle  are  detached  with 
care  from  one  transverse  process.  The  finger  introduced  reaches  with- 
out difficulty  the  anterior  surface  of  the  vertebral  bodies.  The  finger 
can  strip  up  the  psoas  muscle  through  this  incision  and  explore  the 
vertebral  bodies.     The  vertebral  canal  should  not  be  opened. 

Treatment  of  Abscess. 

Abscesses  may  be  treated  by  expectancy  or  by  operation. 

(i)  Expectancy. — Under  proper  treatment  early  abscesses  may 
subside  and  be  absorbed  without  detriment  to  the  patient. 

Recumbency  under  the  best  mechanical  conditions,  preferably  in 
the  open  air  day  and  night,  will  favor  the  tendency  to  absorption. 
Aspiration  will  diminish  the  size  of  an  abscess,  but  if  it  does  not  tend 
to  absorb  under  the  conditions  mentioned,  and  especially  if  it  shows  a 
tendency  to  increase,  it  is  better  not  to  temporize,  but  to  incise.  The 
injection  of  abscess  cavities  with  germicidal  solutions  should  be  re- 
garded as  imperfect  and  not  meeting  the  surgical  indication  of  drain- 
age. 

(2)  Operation. — When  abscesses  increase  rapidly,  or  for  any  reason 
seem  an  injury  to  the  patient,  incision  is  to  be  considered. 

Incision  of  an  abscess  should  be  made  under  thorough  aseptic  pre- 
cautions, and  as  complete  drainage  as  possible  secured ;  but  it  must  be 
remembered  that  owing  to  the  depth  of  the  origin  of  abscesses  in  Pott's 


8o  ORTHOPEDIC  SURGERY. 

disease  perfect  drainage  is  not  always  as  easily  furnished  as  in  more 
superficial  abscesses.  It  is  therefore  desirable,  especially  in  adults,  to 
delay  incision  longer  than  would  otherwise  be  surgically  indicated.  It 
is  also  to  be  remembered  that  as  the  focus  of  the  disease  has  not  been 
reached,  a  discharging  sinus  will  persist  and  will  ultimately  become  in- 
fected with  pyogenic  organisms,  thereby  adding  a  pyogenic  to  a  tuber- 
culous infection.' 

In  retrophar}-ngeal  and  cervical  abscesses,  however,  drainage  can 
ordinarily  be  readily  secured.  In  dorsal  abscesses  an  incision  in  the 
back  is  frequently  sufficient ;  but  in  some  instances  it  will  be  necessary 
to  perform  costo-transversectomy  to  secure  perfect  drainage.  In  lum- 
bar and  iliac  abscesses  it  may  be  necessary,  owing  to  the  depth  of  their 
origin,  to  incise  both  in  front  and  behind,  which  can  be  done  with  care 
without  opening  the  peritoneal  cavity. 

The  above-mentioned  facts  must  be  borne  in  mind  in  advocating 
operation  when  it  is  not  indicated  by  pressure  effects  and  the  distention 
of  the  abscess. 

Psoas  abscess  may  be  opened  in  the  loin  or  in  the  iliac  fossa,  or  in 
both  places.  Drainage  may  be  made  with  a  strip  of  gauze  or  a  rubber 
tube  and  the  dressing  kept  sterile  as  long  as  possible.  After  incision 
curettage  is  not  desirable,  as  it  is  impossible  to  remove  all  of  the  dis- 
eased material  and  unnecessary  traumatism  is  to  be  avoided.  Flushing 
with  sterile  hot  water  is  all  that  is  required.  It  must  be  remembered 
that  communication  in  front  of  the  vertebral  column  may  exist  between 
the  psoas  sheath  of  one  side  and  that  of  the  other. 

A  rctropJiajyiigeal  abscess  is  best  opened  by  passing  into  the  mouth 
a  bistoury  wound  to  within  half  an  inch  of  its  point  with  cotton,  and 
cutting  freely,  using  the  finger  as  a  guide.  The  child  should  be  held 
face  downward  in  order  that  the  pus  may  not  enter  the  trachea,  and 
plenty  of  swabs  should  be  at  hand  to  keep  the  mouth  clear,  for  the 
gush  of  pus  is  sometimes  considerable.  Such  abscesses  may  also  be 
opened  by  lateral  incisions  from  the  outside. 

Abscess  in  the  incdiastinnm  is  opened  as  described  above  in  speak- 
ing of  costo-transversectomy. 

Other  abscesses  are  opened  on  general  surgical  principles. 

Treatment  of  Psoas  Contraction. — When  flexion  of  one  or  both 
thighs  has  come  on  it  is  not  likely  to  diminish  spontaneously,  and  if 
"the  condition  is  allowed  to  go  untreated,  such  contractions  may  become 
permanent. 

A  permanent  contraction  of  one  or  both  psoas  muscles  with  the 
thigh  flexed  is  a  serious  deformity.  If  it  exists  on  both  sides,  the  pa- 
tient can  walk  only  with  the  trunk  held  nearly  horizontal.  If  it  is  uni- 
lateral, it  leads  to  a  very  serious  disability,  requiring  in  most  cases  the 
'  Schuckhardt  and  Krause  :  "  Die  Tub.  der  Knochen  und  Gelenke." 


TUBERCULOUS  DISEASE   OF   THE  SPINE.  8i 

use  of  a  crutch,  for  the  diseased  spine  cannot  be  flexed  to  allow  the  foot 
to  reach  the  ground  in  walking  as  it  does  when  flexion  of  the  thigh 
exists  as  a  result  of  hip  disease.  For  these  reasons  it  is  desirable  to 
attack  psoas  contraction  with  very  vigorous  measures,  which  afford  a 
prospect  of  averting  any  permanent  contraction. 

In  the  early  stages  the  child  should  be  put  to  bed  on  a  frame.  A 
light  extension  should  be  applied  to  the  leg  with  pulley  extension,  and 
the  pulley  should  be  gradually  lowered  until  the  leg  is  straight  and  the 
flexion  overcome.  In  cases  in  which  the  flexion  has  existed  only 
a  few  weeks  or  months,  this  is  generally  easily  accomplished  in  two 
or  three  weeks.  If  not,  or  if  a  more  rapid  method  is  desired  in  the  first 
instance,  the  child  should  be  anaesthetized  and  the  leg  straightened 
by  force  and  retained  by  plaster  of  Paris.  If  this  cannot  be  done 
with  the  use  of  moderate  force,  it  is  better  to  divide  and  cut  the 
fascia  and  the  contracted  bands — an  operation  which  cannot  often  be 
done  thoroughly  subcutaneously,  for  there  are  many  deep  bands. 

The  deformity  is  almost  sure  to  return  if  the  patients  are  allowed  to 
go  about,  and  they  should  either  be  kept  on  a  frame  or  an  arm  should 
be  extended  down  from  the  brace  or  the  jacket  to  keep  the  thigh  fully 
extended.  Finally,  subtrochanteric  osteotomy  of  the  femur  may  be 
necessary  in  severe  cases,  but  it  should  not  be  done  until  after  recovery 
from  the  Pott's  disease. 

Treatment  of  Paralysis. 

When  paralysis  is  threatened,  the  patient  should  be  put  to  bed  on  a 
frame  so  padded  as  to  press  upon  the  deformity  and  hold  the  vertebrae 
somewhat  separated.  In  dorsal  cases  traction  may  be  added.  An 
attack  may  thus  be  averted. 

When  paralysis  is  present,  a  plaster  jacket  should  be  applied  in 
strong  hyperextension  of  the  spine  at  the  seat  of  the  deformity  (by  one 
of  the  methods  mentioned),  and  the  patient  should  be  kept  recumbent 
until  the  paralysis  begins  to  disappear. 

The  tendency  of  the  paralysis  is  strongly  toward  recovery  under 
favorable  conditions  of  treatment.  Taylor  and  Lovett  found,  in  forty- 
seven  cases  in  private  practice,  eighty-three  per  cent  of  recoveries. 
The  average  duration  of  the  cases  was  one  year,  but  when  the  paralysis 
came  under  treatment  the  average  was  only  seven  months.  Relapses 
occur  at  times,  and  although  the  loss  of  sensation  and  paralysis  of  the 
sphincters  are  symptoms  pointing  to  a  serious  involvement  of  the  cord, 
recovery  may  follow. 

These  considerations  bear  strongly  on  the  question  of  operative 
treatment  for  paralytic  cases. 

Drugs  are  of  little  or  no  value,  and  it  is  not  possible  to  attach  much 
importance  to  the  use  of  the  cautery  or  of  counterirritants. 
6 


82  ORTHOPEDIC  SURGERY. 

Laminectomy. — A  spicule  of  bone  or  an  intraspinal  abscess  may  be 
the  source  of  pressure  at  any  stage  of  the  disease,  and  in  such  cases, 
of  course,  operation  is  demanded.  In  cases  of  long  standing  in  which 
the  paralysis  has  become  very  extensive  and  has  involved  sensation, 
and  possibly  the  sphincters  of  the  bladder  and  rectum,  the  question 
arises  as  to  whether  the  operation  is  likely  to  be  of  benefit  or  whether 
the  damage  to  the  cord  is  not  already  irreparable. 

The  operation  consists  in  cutting  down  upon  the  spinous  processes 
in  the  region  of  the  deformity,  the  incision  being  slightly  to  one  side  of 
the  centre,  so  that  the  resulting  cicatrix  will  not  be  unduly  pressed 
upon  during  recumbency.  All  the  soft  tissues  are  then  stripped  with 
a  periosteal  knife,  until  the  laminae  are  exposed.  The  spinous  processes 
are  then  removed  with  bone  forceps  over  the  affected  area.  Laminec- 
tomy forceps  are  then  used  to  cut  awa}'  all  of  the  laminae  covering  the 
cord  at  the  seat  of  pressure.  The  dura  ma}'  or  may  not  be  opened. 
A  probe  is  then  passed  up  and  down  the  spinal  canal,  to  be  sure  that 
all  pressure  is  removed,  and  the  wound  is  dressed.  The  patient  should 
be  laid  on  the  face  after  operation  if  it  is  more  comfortable. 

It  may  be  said  that  resection  of  the  laminae  of  the  vertebral  column 
is  an  operation  which  is  not  gaining  in  fa\'or.  The  death  rate  is  high 
(36.44  per  cent),  and  with  the  more  efficient  treatment  of  paralysis  by 
mechanical  means  laminectoni}'  must  be  reser\'ed  for  the  gravest  cases 
which  show  no  sign  of  improvement  after  a  faithful  and  long-continued 
trial  of  the  ordinary  measures.  But  at  the  same  time  brilliant  suc- 
cesses at  times  follow  the  operation,  so  that  it  holds  out  the  hope  of 
relieving  cases  of  paraplegia  which  would  otherwise  have  been  hope- 
less. The  operation,  however,  has  no  place  in  the  treatment  of  Pott's 
disease  until  the  conser\'ative  measures  have  been  faithfully  tried  over 
a  sufficient  period  of  time — measures  Avhich  in  most  cases  will  prove 
efificient  and  successful  in  the  relief  of  the  paralysis.  Immediate  im- 
provement is  not  necessarily  to  be  expected. 

SUMMARY   OF   TREATMENT. 

The  proper  treatment  of  Pott's  disease  is  not  the  application  of  any 
method,  the  use  of  any  corset  or  brace,  but  the  employment  of  such 
means  as  are  most  efficient  for  carrying  out  the  object  aimed  at.  A 
brace  is  useless  in  the  case  of  persons  unable  to  adjust  it;  a  plaster 
jacket  applied  about  the  trunk  is  useless  in  disease  of  the  cervical  or 
high  dorsal  region.  Recumbency,  carried  to  a  point  of  depressing  the 
patient's  mental  and  physical  condition,  is  as  much  of  a  mistake  as 
to  drag  a  patient  ab(3ut  who  is  anxious  to  lie  down. 

In  the  treatment  of  these  cases,  the  surgeon  should  be  familiar  with 
the  advantages  to  be  gained  by  all  methods,  and  should  emplo}'  each 


TUBERCULOUS    DISEASE   OF    THE  SPINE.  83 

as  the  case  may  demand,  and  for  such  a  length  of  time  as  the  circum- 
stances of  the  case  may  require,  or  combine  the  different  methods  as 
ma}'  be  advisable. 

In  a  general  way  he  may  formulate  to  himself  that :  in  acute,  painful 
cases  absolute  recumbency  with  proper  fixation  is  the  best  method  until 
the  active  stage  of  the  disease  is  passed ;  in  middle  and  lower  dorsal 
Pott's  disease  an  immovable  plaster  jacket,  without  head  attachment, 
in  the  case  of  negligent  persons,  is  most  available. 

Whether  recumbency  for  a  time  is  required,  or  whether  ambula- 
tory treatment  with  fi.xation  appliances  is  sufficient,  are  cjuestions  of 
judgment  in  individual  cases. 

A  choice  between  plaster  jackets  and  steel  appliances  is  a  choice 
between  a  fixed  and  a  movable  support.  The  former  is  better  in  the 
more  acute  forms  of  the  disease.  The  latter  requires  constant  and 
faithful  attention  to  guard  against  imperfect  or  loose  application  and  in- 
adequate support. 

Apparatus  carefull)-  adjusted  and  applied  is  evidently  preferable  to 
removable  plaster  and  other  corsets,  being  less  clumsy,  but  apparatus 
properly  made  is  both  more  expensive  and  demands  more  skill  and  time 
on  the  part  of  the  surgeon. 

In  cases  of  Pott's  disease  the  treatment  involves  much  responsibility 
and  cannot  be  left  to  a  mechanician  unfamiliar  with  the  pathological 
conditions,  as  is  sometimes  done.  The  surgeon  should  familiarize  him- 
self with  every  detail  and  be  responsible  for  this  as  well  as  for  the  gen- 
eral treatment. 


CHAPTER    III. 

TUBERCULOUS    DISEASE    OF    THE    HIP. 

Definition. — Pathology. — Clinical   history. — Diagnosis. — Differential  diagnosis. — 
Prognosis. — Treatment  (mechanical — operative). 

The  affection  which  is  commonly  known  as  hip  disease  is  the  most 
frequent  affection  of  the  hip-joint,  and  by  common  usage  the  general 
name  of  "hip  disease"  or  "hip-joint  disease  "has  become  limited  to 
that  especial  affection  of  the  joint  which  comes  now  for  consideration. 
It  is  known  also  by  the  names  of  morbus  coxarius  or  morbus  coxse, 
coxalgia,  coxitis,  chronic  articular  ostitis  of  the  hip,  and  coxo-tubercu- 
lose  (Lannelongue).  The  pathological  condition  commonly  found  is  a 
chronic  tuberculous  ostitis  of  the  epiphysis  of  the  head  of  the  femur  or 
of  the  acetabulum. 

PATHOLOGY. 

The  pathology  of  hip  disease  in  general  does  not  differ  from  that  of 
tuberculous  disease  of  bone  which  has  already  been  referred  to. 

The  head  of  the  femur  is  the  primary  seat  of  disease,'  in  a  majority 
of  the  cases  the  epiphysis  or  juxto-epiphyseal  region  being  the  part  at- 
tacked. In  about  twenty-five  per  cent  of  the  cases  the  primary  focus 
is  in  the  acetabulum. 

When  once  the  acetabulum  has  become  diseased  either  primarily  or 
secondarily,  enlargement  of  it  is  apt  to  take  place.  The  irritated  pelvic 
femoral  muscles  which  are  in  a  state  of  tonic  contraction  crowd  the 
head  of  the  femur  against  the  upper  and  back  border  of  the  acetabulum  ; 
under  this  continual  pressure  absorption  of  that  portion  of  the  rim  of 
the  acetabular  cavity  takes  place  with  an  actual  enlargement  of  the  cav- 
ity from  below  upward.  This  so-called  migration  of  the  acetabulum  is 
one  cause  of  shortening  of  the  limb,  and  measurement  will  show  that 
the  trochanter  lies  above  Nelaton's  line. 

The  changes  in  the  head  of  the  femur  are  chiefly  the  result  of  ostitis 
and  pressure.  There  may  be  alteration  in  the  shape  of  the  head  of  the 
bone,  if  it  is  worn  away  by  the  pressure  induced  by  constant  muscular 
spasm  with  destruction  of  the  articular  surface. 

^  Konig  :  Deutsch.  Zeit.  f.  Chir  .  xi..  1S79. — Konig:  "Die  spec.  Tuberc.  der 
Knochen  und  Gelenke."  Pt.  II..  Berlin.  1903. — G.  A.  Wright:  "Hip.  Dis.  in  Child- 
hood." p.  17. — Habern:  Cent.  f.  Chir.,  April  2d,  iSSi. — E.  H.  Nichols:  Orth. 
Trans.,  vol.  xi,.  p.  353. 

84 


TUBERCULOUS  DISEASE   OF   THE  HIP. 


!5 


"  Dislocation  "  of  the  hip  in  hip  disease  is  a  term  often  used  which 
is  perhaps  misleading.  Partial  destruction  of  the  softened  head  of  the 
femur  in  the  manner  just  described  may  lead  to  a  shortening  of  the 
limb  and  to  an  elevation  of  the  trochanter  above  its  proper  level.  The 
wearing  away  of  the  acetabulum  produces  the  same  result ;  but  true 
dislocation  is  rare,  because,  even  if  the  head  of  the  bone  is  almost  en- 


Fig.  83.— Frontal  Section  through  a  Normal  Right  Hip  Joint  in  an  Adult. 

tirely  destroyed,  there  is  so  much  inflammatory  tissue  deposited  about 
the  joint  that  the  head  of  the  bone  is  retained  partly  in  place. 

Fracture  of  the  atrophied  and  degenerated  shaft  of  the  femur  may 
occur  in  occasional  cases.  Separation  of  the  head  of  the  femur  at  the 
epiphyseal  line  is  less  uncommon. 

A  typical  specimen  from  a  fairly  advanced  case  of  hip  disease  shows 
a  reddened  and  thickened  synovial  membrane,  often  with  granulations ; 
the  cartilage  is  gone  from  the  head  of  the  femur  or  hangs  in  tags  or 
shreds,  and  the  general  appearance  of  the  end  is  often  spoken  of  as 


86 


ORTHOPEDIC  SURGERY. 


"worm-eaten";  sometimes  the  whole  cartilage  may  be  lifted  from  the 
bone  h\  a  la}er  of  granulations.     The  epiphyseal  portion  of  the  head  of 
the  femur  has  disappeared  in  part  or  altogether,  and  a  ragged,  carious - 
end  of  bone  will  articulate  with  an  acetabulum  covered  with  fungous 
granulation  in  part  or  wholly  replacing  cartilage. 

The  whole  epiph)'sis  may  form  one  sequesti'um,  but  this  is  not  com- 
mon in  tuberculous  ostitis,  though  not  as  rare  in  infectious  ostitis. 


Fig.  84. — Erosion  of  the  Upper  Part  of  the  Acetabulum.     (Warren  Museum.) 

Perforation  of  the  floor  of  the  acetabulum  may  take  place.  Inside 
of  the  pelvis  a  dense  wall  of  fibrous  tissue  and  thickened  periosteum 
shuts  off  the  head  of  the  femur  or  the  contents  of  the  joint  from  the 
pelvic  cavity.  In  cases  in  which  the  disease  has  gone  on  as  far  as  this, 
disease  of  the  pelvic  bones  may  coexist.  In  the  other  direction,  when 
once  the  disease  of  the  femur  has  passed  the  epiphyseal  line,  there  is  no 
limit  to  be  set  to  its  course  or  its  extent  of  destruction. 

Abscesses  appear  externally  if  the  disease  of  the  joint  extends  to 
the  periarticular  tissues  or  when  a  separate  focus  of  disease  forms  out- 


TUBERCULOUS  DISEASE   OF   THE  HIP. 


^7 


side  of  the  joint  and  si)reads  to  the  surrounding,^  soft  i)arts.     Suppura- 
tion inside  of  the  pelvis  is  not  a  \'ery  uncommon  condition  in  the  ace- 


FlG.  85.— Focus  in  Head  of  Femur. 

tabular  form  of  the  disease;    in  the  femoral  form  it  accompanies  only 
advanced  disease. 

A  natural  cure  results  in  one  of  two  ways :  by  the  absorption  or  cal- 


FlG.  86.— Separation  of  the  Head  ot  tiie  Keniiir  ar  the  Epiphyseal  Line. 

cification  of  the  tuberculous  tissue  at  an  early  or  a  late  stage  of  the  dis- 
ease; or  by  the  purulent  degeneration  of  such  tissue  and  its  evacuation 
and  discharge  by  an  external  opening.     The  suppuration  which  comes 


88 


ORTHOPEDIC  SURGERY. 


later  seems  to  be  nature's  effort  to  eliminate  the  diseased  material,  and 
it  is  the  common  method  by  which  spontaneous  cure  results  when  it 
does  occur.  This  late  stage  of  the  disease  is  characterized  by  malposi- 
tions and  shortening  of  the  limb  and  much  impairment  of  the  general 
condition  in  most  cases.  It  is  this  state  of  affairs  that  makes  the  spon- 
taneous cure  of  hip  disease  undesirable  and  imperfect.  When  sponta- 
neous cure  does  occur  it  is  usually 
with  an  ankylosed  joint. 

In  these  cases,  however,  one 
sometimes  finds  at  autopsy  an  in- 
cluded cheesy  focus  which  still  pre- 
sents some  signs  of  activity.  It  is 
to  these  foci  that  one  looks  for  an 
explanation  of  the  late  relapses  of 
the  disease  and  the  very  great  harm 


Fig.  87.— Hip.  Excised  head  of  femur.  Artic- 
ular cartilage  turned  up  at  one  side  shows 
tuberculous  bone  beneath.  Primary  focus 
was  in  acetabulum,  a,  Head  of  femur, 
surface  tubercles ;  5,  elevated  cartilage. 
(NichoLs.) 


Fig.  88. — Acetabulum  Seen  from  Outside, 
a,  Tviberculous  granulations;  b,  tubercu- 
lous cavity.     (Nichols.) 


which  is  sometimes  done  by  forcible  manipulation  of  these  joints  and 
consequent  lighting  up  of  the  original  tuberculous  disease.' 


CLINICAL   HISTORY. 

Early  Symptoms. — The  beginning  of  the  affection  is  most  often 
gradual  and  insidious,  but  at  times  it  begins  so  abruptly,  according  to 
the  parents'  account,  as  to  suggest  a  traumatic  origin.  The  child  will 
be  noticed  to  limp  at  times  with  intervals  of  comparative  freedom  from 
lameness.  This  lameness  increases,  and  it  will  be  found  that  the  patient 
is  inclined  to  strike  the  ball  of  the  foot  rather  than  the  heel  in  walking ; 
although  the  heel  can  be  put  down  to  the  floor,  yet  instinctively  the 
knee  is  slightly  bent  and  the  heel  raised  when  the  weight  of  the  trunk 
falls  on  the  hip.  There  is  a  certain  amount  of  stiffness  of  gait  apparent 
in  the  morning  when  the  patient  first  gets  out  of  bed,  and  after  sitting 

'  Trans.  American  Orthopedic  Association,  vol.  i. 


TUBERCULOUS  DISEASE  OF   THE  HIP. 


89 


for  a  while ;  this  passes  away  after  the  patient  has  walked  or  played 
about.  At  night,  as  a  rule,  the  limp  is  less  than  in  the  morning.  The 
limp  can  perhaps  best  be  described  as  a  very  slight  stiffness  and  a  dis- 
inclination to  bear  prolonged  weight  upon  the  affected  limb. 

If  the  child  be  inspected  it  will  be  seen  that  in  standing  the  knee  of 
the  affected  side  is  often  flexed  slightly,  the  pelvis  being  tipped  and 
the  thigh  slightly  abducted.  The  tilting  of  the  pelvis  and  abduction 
of  the  thigh  may  be  so  slight  that  it  is  scarcely  noticeable,  except  by 


Fig.  8g.— Head  of  Femur  Eroded,  Partly  Destroyed,  Partly  Dislocated.     Fibrous  ankylosis. 
<;,  Head  of  femur;  b,  eroded  head  of  femur;  c,  ankylosis;  d^  acetabulum.     (Nichols.) 


the  deviation  from  the  median  line  of  the  fold  between  the  two  but- 
tocks. In  girls  the  vulva  on  the  affected  side  may  be  lower  than  on  the 
other  side. 

Pain  at  this  stage  is  very  often  absent,  and  if  present  is  noted  as 
night  cries,  to  which  allusion  will  be  made. 

Course  of  Disease. — It  has  been  customary  to  divide  hip  disease  into 
stages  and  to  ascribe  to  these  stages  certain  definite  symptoms.  Neither 
from  a  clinical  nor  a  pathological  standpoint  is  it  desirable  to  attempt 
any  such  division. 

In  the  early  part  of  the  disease  pain  at  night,  stiffness,  and  limping 


<)0 


OK  THOPEDIC  S  UR  GER  3 : 


are  the  chief  symptoms.     Then  follow  malpositions  of  the  limb,  more 
severe  disabilit}-,  and  perhaps  greater  pain  and  sensitiveness. 

Succeeding  the  deformities  which  have  just  been  described,  one 
may  find  abscess  formation  and  the  development  of  sinuses ;  and  this 

stage  of  the  affection  will 
hardly  haA'e  been  reached 
without  considerable  con- 
stitutional deterioration, 
\\hich  ma}' become  severe. 
Lameness. — From  be- 
ing at  first  scarcel)^  per- 
ceptible, the  lameness 
increases  and  the  limp 
becomes  very  noticeable. 
In  very  acute  cases  pain 
may  become  so  se\-ere  that 
the  child  will  refuse  to 
use  the  leg,  or  malposition 
of  the  leg  may  come  on 
rapidl)'  and  the  limp  ma}" 
on  that  account  become 
excessive;  but  in  general 
the  child  walks  without 
pain,  though  perhaps  limp- 
ing badly.  Until  the  late 
stages  of  the  disease  lame- 
ness is  not  due  to  bone 
shortening. 

Pain. — As    the    affec- 
tion   progresses,    pain    in 
the  knee  and  sensitiveness 
to  jarring  the   limb   may 
become  prominent   symp- 
toms.     An     unconscious 
protection  of  the  joint  may 
be   noticed    in    the  move- 
ment of  the  patient ;  the 
foot  of  the  well  limb  may 
be  placed  under  the  lower 
part  of  the  other  leg  when 
it  is  to  be  suddenly  lifted  by  the  patient,  as  from  the  floor  to  the  bed, 
or  from  the  bed  to  the  floor,  or  in  moving  from  one  side  of  the  bed  to 
the  other. 

In  manipulating  the  leg  at  this  stage  pain  may  follow  the  slightest 


Fig.  90.— Hip- joint  from  Boy  Nine  Years  Old.  Hip  dis- 
ease had  existed  six  years  previously  and  had  been 
treated  by  traction.  Death  from  meningitis.  Speci- 
men shows  no  widening:  of  acetabulum,  and  but  little 
alteration  in  the  head  of  the  femur. 


TUBERCULOUS  DISEASE   OE    THE  HIP. 


91 


jar  to  the  joint,  or,  on  the  other  hand,  the  joint  ma\-  l)e  perfectiv  stiff 
from  muscular  spasm  and  yet  mani})ulation  ma\-  l)e  \vholl\-  [)ain]ess.  In 
■other  cases  motion  in  a  certain  arc  is  possil)le  without  causin.i;'  })ain,  but 
when  the  hmits  of  this  arc  are  reached,  further  motion  becomes  painful 
or  is  prevented  b}-  muscular  fixation.  The  sensitiveness  of  the  joint 
may  become  so  ,^■reat.  when  an  acute  stage  supervenes,  that  the  slight- 
est movement  of  the  patient  or  jar  of  the  bed  or  room  causes  extreme 
suffering.  This  stage  ma)' come  suddenly  and  graduall)- pass  away,  the 
pain  diminishing  b}-  degrees  under  the  enforced  treatment  of  rest,  or  it 
may  be  persistent.  A  characteristic  position  is  frequently  taken  by  the 
patient,  who  places  the  well  foot  on  the  dorsum  of  the  foot  of  the 


Fig.  91.  Fig.  92. 

Fig.  Qi. — Specimen  from  E.xcision  of  Hip  when  Traction  has  not  been  Employed.     Severity 

and  duration  of  disease  similar  to  that  of  case  in  Fiy.  92. 
Fig.  92.  — Specimen    from  Excision  of    Hip  Treated  by  Efficient  Traction    for  Three    Years. 

Operation  done  because  of  failure  in  general  condition. 


affected  limb,  exerting  pressure  away  from  the  acetabulum.  Pain  viay 
be  absent  at  any  or  all  stages  of  the  disease,  and  is  not  a  diagnostie  sign 
for  or  against  iJie  presence  of  Jiip  disease.  Sensitiveness  may  be  absent, 
upon  which  condition,  howe\-er,  at  any  time  a  sensitive  condition  of  the 
joint  may  supervene.  The  pain  is  often  remittent,  and  here,  as  in  all 
the  symptoms  of  this  affection,  marked  remissions  ma\'  occur.  The 
location  of  the  pain  is  variable,  but  is  generally  referred  to  the  inside 
and  front  of  the  thigh  near  the  knee  or  directly  at  the  knee-joint.  The 
intimate  relations  and  anastomoses  of  the  sciatic,  obturator,  and  ante- 
rior crural  nerves  seem  to  furnish  the  best  explanation  of  this. 

In  a  minorit}"  of  cases  the  pain  is  referred  to  the  joint  itself.  In 
the  more  acute  cases  sensitiveness  to  pressure  on  the  trochanter  and  to 
deep  pressure  over  the  anterior  surface  of  the  joint  (just  below  the 
anterior  superior  spine  of  the  ilium)  is  present. 


92 


ORTHOPEDIC  SURGERY. 


Night  Cries. — At  an  early  stage  of  the  affection  the  symptoms  of 
"  night  cries  "  often  appear.  They  occur  in  the  early  part  of  the  night 
usually,  and  may  become  an  annoying  symptom.  After  the  patient  is 
asleep,  and  to  all  appearances  entirely  unconscious,  sleep  will  be  inter- 
rupted by  a  cry  as  if  of  severe  pain,  followed  by  moaning  or  crying  for 
a  few  seconds ;  the  child  being  unconscious  or  only  half-conscious  of 
the  cause  of  the  pain.  These  do  not  often  occur  when  the  patient  is 
entirely  awake,  and  are  caused  by  the  spasmodic  twitching  of  the  mus- 
cles abnormally  excitable  from  irritation,  reflex  to  the  inflammation  of 
the  joint.  These  cries  may  be  repeated  fifteen  or  twenty  times  during 
the  night.     They  may  be  entirely  wanting  in  the  mildest  cases. 

Muscular  fixation  (muscular  spasm)  is  always  present  in  some  de- 
gree, restricting  the  joint's  normal  arc  of  motion.  It  is  due  to  a  reflex 
irritability  of  the  muscles  controlling  the  joint,  which  causes  them  to 


Fig.  93. — Instinctive  EfTort  at  Traction  in  Acute  Disease  of  the  Left  Leg.     (Fisk  Prize  Fund 

Essaj'.) 

maintain  a  condition  of  tonic  spasm  of  greater  or  less  degree.  It  dis- 
appears under  full  anaesthesia.  Increased  stiffness  appearing  in  the 
course  of  treatment  is  a  sign  of  inefficient  treatment  or  of  increase  of 
the  disease.  This  muscular  rigidity  is  the  most  important  sign  of  the 
disease,  for  not  only  is  it  the  chief  reliance  in  the  matter  of  diagnosis, 
but  it  is  the  cause  of  the  malpositions  of  the  limb,  of  the  wearing  away 
of  the  acetabulum  and  of  the  head  of  the  bone,  and  it  lies  at  the  root  of 
much  of  the  pain.  It  furnishes  the  most  accurate  index  of  the  progress 
of  the  case,  and  improves  or  becomes  worse  as  the  case  becomes  better 
or  worse.  The  importance  of  the  recognition  and  accurate  study  of 
this  symptom  cannot  be  overestimated. 

If  a  child  with  severe  hip  disease  be  laid  on  his  face  and  lifted  by 
the  legs  with  a  view  to  determining  the  flexibility  of  the  lumbar  spine, 
one  can  often  notice  the  lumbar  muscles  stand  out  like  cords,  and  hold 
the  lumbar  spine  quite  rigid.  This  often  gives  rise  to  the  suspicion  of 
the  coexistence  of  Pott's  disease.  This  symptom  is  present  only  in  the 
severer  forms  of  hip  disease. 


TUBERCULOUS  DISEASE   OF   THE  HIP. 


93 


Atrophy. — A  marked  atrophy  of  the  muscles  of  the  thigh,  hip,  and 
leg  is  characteristic.  It  is  supposed  to  be  reflex  to  the  disease  of  the 
joint.' 

Atrophy  of  the  muscles  controlling  an  inflamed  joint  begins  early 
and  may  be  very  marked,  even  in  simple  acute  synovitis.     That  this  is 
something  more  than  the  mere  atrophy  of  disuse  is  shown  by  the  fact 
that  it  begins  so  sharply  and  so  early, 
that    it  is  greater  in  the  diseased 
limb  than  in  the  well  one  even  when 
the  patient  has  been  in  bed  from 


Fig.    94.— Obliteration     of    Gluteal 
Fold  in  Hip  Disease  of  Right  Side. 


Fig.  95.— Position   Assumed  in    Standing, 
with  Slight  Abduction  of  the  Right  Leg. 


the  first,  and  that  the  muscles,  although  atrophied,  are  not  soft  and 
flabby,  but  tense. 

Diminished  resistance  to  the  passage  of  the  ,r-rays  in  the  epiphyses 
of  the  hip,  indicative  of  greater  vascularity,  may  be  seen  in  the  earlier 
stages  of  hip  disease." 

Increased  patellar  reflex  is  generally  present  in  the  affected  leg  dur- 

^Emile  Valtat:  "  L'Atrophie  Muse,  dans  les  Mai.  Articulaires."  Paris. 
-Lovett  and  Brown:  "The  Diagnostic  Value  of  the  :i-Ray  in  Hip  Disease," 
Phila.  Med  Journ.,  Jan.  2Sth,  1905. 


94  ORTHOPEDIC  SURGERY. 

ing  the  early  part  of  the  disease  and  the  thigh  muscles  show  a  dimin- 
ished contractility  to  the  faradic  current. 

Atrophy  generally  can  be  easily  appreciated  at  an  early  stage  of  the 
disease  by  grasping  the  muscles  in  the  hand  or  b}'  measurement  with  a 
tape.  The  difference  in  the  circumference  of  the  two  thighs  will  be 
perhaps  one-quarter  of  an  inch  to  an  inch,  and  the  difference  in  the  size 
of  the  calves  is  generally  about  half  of  the  thigh  difference.  In  chil- 
dren who  can  use  the  leg  fairly  well  there  is  rarely  any  calf  atrophy  at 
the  first  examination.  The  obliteration  of  the  fold  of  the  buttock  on 
the  affected  side  is  a  result  partly  of  muscular  atroph}'  and  partly  of  the 
periarticular  swelling  which  accompanies  the  disease.  It  is  a  common 
but  not  a  constant  symptom  at  the  early  stages  of  the  disease.  It  is 
also  partly  due  to  the  flexed  attitude  of  the  limb,  which  naturally  di- 
minishes the  prominence  of  the  buttock  on  that  side. 

Malpositions  of  the  Limb. — The  fixation  of  the  diseased  limb  in  a 
distorted  position  is  one  of  the  commonest  incidents  of  the  affection. 


Fig.  96.— Severe  Abduction  and  Eversion  in  a  very  Acute  Case. 

This  is  due  to  the  tonic  muscular  contraction  so  often  alluded  to. 
These  malpositions  may  hold  the  limb  in  flexion,  adduction,  abduction, 
or  eversion,  or  in  any  combination  of  these ;  the  cause  which  deter- 
mines the  kind  of  malposition  in  an  individual  case  cannot  be  formu- 
lated. Flexion  of  the  thigh  is  chiefly  due  to  the  muscular  contraction, 
which  is  constant  in  chronic  disease  of  the  joint,  and  partly  to  an  un- 
conscious effort  on  the  part  of  the  patient  to  assume  a  position  most 
comfortable  for  the  joint  and  most  protected  from  jar.'  These  deform- 
ities ^  generally  disappear  under  treatment  by  rest  or  traction  ;  but  again, 
they  reappear  in  cases  under  treatment  if  treatment  has  not  succeeded 
in  checking  the  progress  of  the  disease.  They  often  accompany  a  sen- 
sitive condition  of  the  joint,  which  may  be  the  precursor  of  abscess. 
If  the  malposition  is  allowed  to  become  permanent  the  final  result 

^  Lannelongue :  "  Coxotiiberculose,"  Paris.  1SS5. — Hilton:  "Rest  and  Pain," 
J.ondon. 

-H.  M.  Sherman:  Orth.  Trans.,  vol.  xii. 


rUBEKCULOUS  DISEASE   OE    THE  HIP 


9S 


can  never  l)e  so  t;()()(l  as  when  cicatrization  takes  i)lace  in  a  more  nor- 
mal position.  The  Hmp  in  ank)losecl  limbs  clei)encls  more  u[M)n  the 
amount  of  flexion  and  adduction  than  on  an)  thin^i^  except  perhaps  the 
bone  shortening'.  It  is,  therefore,  of  much  importance  to  diminish  in 
all  cases  the  amount  of  malposition  present. 

When  adduction   is  present  in  both  legs,  as  in  double  hip  disease,, 
and  ankylosis  of  both  hips  has  oc- 
curred,    cross-legged      progression 
may  be  necessary  on  accfumt  of  the 
inability  to  separate  the  legs. 

The  position  in  standing  and  ly- 
ing is  modified  by  the  occurrence  of 
these  malpositions;  abduction  or 
adduction  causes  tilting  of  the  pelvis, 
and  flexion  causes  a  marked  lordo- 
sis of  the  lumbar  spine  in  standing 


Fig.  97, — Adduction  of  the  Left  Leif  in  Acute 
Hip  Disease. 


Fig.    9S.— Case  Showing  Marked  Flexion 
with  Adduction  of  the  Left  Hip  Joint. 


with  the  legs  parallel ;  by  standing  with  the  diseased  leg  somewhat 
flexed  the  lordosis  can  be  overcome.  The  same  arching  of  the  lumbar 
spine  occurs  when  the  patient  lies  on  a  table  and  the  flexed  leg  is 
brought  down. 

Periarticular  Symptoms. — An  important  sign  is  found  in  the  thick- 
ening over  the  anterior  surface  of  the  joint  when  palpated  in  the  groin 
as  contrasted  with  the  other  side.  An  indefinite  o\-al  thickened  area 
is  felt  deep  down.     At  other  times  the  thickening  is  most  marked  at 


96 


ORTHOPEDIC  SURGERY. 


the  posterior  aspect  of  the  joint,  behind  the  trochanter.  This  sign  is 
an  early  one  and  of  great  value  in  the  early  recognition  of  the  disease. 
A  density  in  the  superficial  tissues  over  a  diseased  hip  which  the  other 
side  does  not  possess  is  often  found  at  a  comparatively  early  stage  of 
the  affection.  Behind  or  in  front  of  the  trochanter  the  deep  tissues  are 
resistant  and  the  fossa  existing  there  is  filled  out,  and  the  great  tro- 
chanter feels  enlarged  and  thicker  than 
its  fellow  when  grasped  by  the  fingers 
deeply  pressed  in. 

The  inguinal  glands  of  the  affected 
side  are  often  enlarged  and  they  may 
be  so  much  distended  that  they  ob- 
struct the  venous  return  and  the  skin 
may  be  marbled  with  superficial  veins. 
They  are  at  times  the  seat  of  super- 
ficial abscesses.  A  gland  lying  on  the 
iliac  vessels  is  frequently  found  en- 
larged in  hip  disease  and  is  palpated 
just  above  the  ramus  of  the  pubis. 
In  very  severe  cases  the  upper  part  of 
the  thigh  and  the  tissues  in  the  vicinity 
of  the  hip  may  become  swollen  gener- 
ally from  an  oedema  of  the  periarticular 
tissues.  This  may  disappear  or  be- 
come localized  in  the  formation  of  an 
abscess. 

Abscess. — In  a  proportion  of  cases 
suppuration  takes  place.  The  site  and 
course  of  the  abscesses  vary  accord- 
ing to  the  seat  and  size  of  the  original 
focus  of  the  ostitis,  whether  in  the 
femur  or  acetabulum.  Abscesses  may 
be  entirely  periarticular,  if  the  initial 
lesion  of  the  epiphysis  extend  in  a 
course  outside  of  the  joint;  or,  as  is 
commonly  the  case,  they  may  come 
joint;    or,    having   been   periarticular. 


Fig.  99. —Left  Hip  Disease  with  Abscess 
on  Outer  Side  of  Thigh. 


from    suppuration    within    the 
they  may  later  involve  the  joint. 

The  invasion  of  the  abscess  is  frequently  without  constitutional  dis- 
turbance; exacerbation  of  pain  and  joint  symptoms  is,  however,  a  fre- 
quent accompaniment  of  this  formation.  Abscesses  may  be  absorbed 
or  may  evacuate  themselves  spontaneously  either  completely  or  par- 
tially, the  residual  fluid  following  along  the  course  of  the  sheaths  of  the 
muscles  and  the  fasciae,  reappearing  later  as  secondary  abscesses,  the 


TUBERCULOUS  DISEASE   OE   THE  HIP.  97 

same  abscess  causing  five  or  six  fistulous  openings.  These  openings 
discharge  pus  and  serum  for  months  and  years  in  most  cases.  These 
sinuses  after  a  short  time  become  infected  with  pyogenic  organisms. 
With  the  bursting  of  an  abscess  and  the  discharge  of  any  considerable 
quantity  of  pus  the  patient's  condition  may  show  rapid  improvement, 
or,  if  imperfect  drainage  takes  place,  reaccumulation  of  the  pus  may 
occur  and  the  patient's  condition  may  become  worse. 

When  the  pus  has  left  the  joint  it  generally  burrows  between  the 
thigh  muscles  to  reach  the  skin,  where  it  appears  as  a  swelling  of  vary- 
ing size.  Fluctuation  is  usually  marked.  As  the  abscess  invades  the 
skin  the  latter  becomes  thin  and  red,  and  ulcerates  in  one  or  two  places, 
evacuating  the  abscess.  The  contents  of  the  abscess  may,  however,  in 
a  few  instances  be  absorbed  even  at  a  stage  when  fluctuation  is  marked, 
and  the  swelling  may  disappear,  perhaps  leaving  a  depression  beneath 
the  skin. 

The  pus  most  commonly  reaches  the  skin  at  the  anterior  border  of 
the  tensor  vaginae  femoris  muscles ;  it  may,  however,  gravitate  back- 
ward and  open  back  of  the  great  trochanter  or  at  the  lower  border  of 
the  glutaeus  maximus ;  it  may  come  around  to  the  inner  side  of  the 


Fig.  100. — Deformity  in  Untreated  Double  Hip  Disease. 

thigh  and  perhaps  open  in  front  of  the  adductor  tendons  or  even  dis- 
charge into  the  rectum ;  finally,  it  may  ascend  the  sheath  of  the  psoas 
muscles  and  point  above  Poupart's  ligament,  or  it  may  descend  in  the 
thigh  muscles  and  point  in  the  popliteal  space.  The  seat  of  the  primary 
disease  cannot  be  inferred  from  the  situation  of  the  abscess. 

Abscess  is  very  often  the  result  of  inefficient  treatment  and  im- 
proper care.i 

Shortening. — The  effect  of  persistent  muscular  spasm  of  muscles 
about  the  hip-joint,  characteristic  of  hip  disease,  is  to  crowd  the  femur 
'  Lovett  and  Goldthwait :  Ortho.  Trans.,  vol.  ii.,  p.  82. 

7 


98 


ORTHOPEDIC  SURGERY. 


against  the  acetabulum  and  to  produce  the  enlargement  of  the  acetabu- 
lum and  the  absorption  of  the  head  of  the  femur,  with  resulting  shorten- 
ing of  the  limb. 

In  addition  to  the  shortening  produced  by  absolute  destruction  of 
bone  in  the  femur  or  the  acetabulum,  there  is  a  decided  trophic  dis- 
turbance of  the  limb  which  results  in  retarding  the  bony  growth  and 
causes  at  the  same  time  a  certain  amount  of  bone  atrophy ;  retarded 
growth  of  the  affected  limb  becomes  evident  in  the  early  months  of  the 
disease,  and  is  a  permanent  condition  which  is  not  outgrown  as  years 

go  on,  for  the  affected  limb 
always  lags  behind  the  other 
in  its  growth. 

The  shortening  may  be  even- 
ly distributed  between  the  bones 
of  the  leg  and  those  of  the  thigh, 
or  it  may  be  most  marked  in 
the  bones  of  the  leg.  When 
there  is  much  shortening  of  the 
leg,  the  foot  of  the  affected  side 
is  also  smaller  than  the  other. 
The  difference  in  the  length  of 
the  legs  almost  always  increases 
slightly  after  the  disease  is 
cured.' 

General  Condition. — Chil- 
dren with  hip  disease  are  often 
robust  at  the  beginning  of  the 
affection  and  sometimes  the 
general  condition  continues 
good,  but  these  cases  are  excep- 
tional. More  often  the  child  is 
pale  and  the  appetite  fails  at 
times;  there  is  often  loss  of 
flesh ;  in  some  mild  cases  and  in  most  of  the  severe  ones  decided  con- 
stitutional disturbance  results. 

Remissions. — Any  account  of  the  symptoms  of  hip  disease  would  be 
incomplete  without  speaking  of  the  remissions  in  the  course  of  the 
affection.  In  the  early  stage  this  is  especially  noticeable,  and  a  patient 
may  to  outside  appearances  entirely  recover  from  the  symptoms  of  pain, 
lameness,  and  discomfort  for  some  days  or  weeks.  Then  the  symptoms 
return  with  increased  vigor,  perhaps  to  disappear  again  in  a  short  time. 
The  muscular  stiffness  does  not  wholly  disappear  at  these  times, 
although  it  may  improve  along  with  the  other  manifestations  of  the  dis- 
1  Shaffer  and  Lovett:  N.  Y.  Med.  Jour.,  May  21st,  18S7. 


FlG^  loi.  — Position  Necessitated  \>y  the  Perma- 
nent Flexion  Deformity  Resulting  from 
Double  Hip  Disease. 


TUBERCULOUS  DISEASE   OF   THE  HIP. 


99 


ease.     The  later  course  of  the  disease  is  marked  by  much  greater  uni- 
formity, but  even  then  temporary  improvement  may  be  quite  marked. 

Temperature. — Chikh-en  with  hip  disease  under  treatment  by  ambu- 
latory measures  have  as  a  rule  a  higher  afternoon  temperature  than 
normal.  In  627  observations  made  on  cases  of  hip  disease  and  Pott's 
disease  at  the  Out-Patient  Department  of  the  Children's  Hospital  a  rise 
of  temperature  of  one  or  two  degrees  was  common.  Ninety  per  cent 
of  all  cases,  acute  or  chronic,  mild  or  severe,  had  an  evening  tempera- 
ture of  at  least  99°,  and  a  rise  to  103°  or  104°  in  severe  cases  was  not 
necessarily  an  indication  of  ab- 
scess. 

Double  Hip  Disease. — The  dis- 
ease seldom  begins  in  both  hip- 
joints  at  the  same  time,  and  the 
second  joint  may  become  inflamed 
while  the  patient  is  under  treat- 
ment in  bed  for  the  first  joint. 

The  course  of  double  hip  dis- 
ease would  appear  to  vary  some- 
what from  that  of  single  hip  dis- 
ease. It  is,  as  a  rule,  of  a  severe 
t\pe  and  tends  strongly  to  ank}-- 
losis.  The  amount  of  pain  suf- 
fered in  the  joint  last  affected  is 
usually  less  than  that  of  the  first 
joint,  probably  because  there  is 
less  jar  or  motion  when  two  hip- 
joints  are  affected  than  when  one 
alone  is  attacked. 

Malpositions  are  more  than  usually  troublesome  and  may  be  differ- 
ent in  the  two  hips.  Recovery  without  deformity  and  with  as  much 
motion  as  possible  is  most  important  in  double  hip  disease. 


Progression   in  a    Case   of   Severe 
Double  Hip  Disease. 


DIAGNOSIS. 

The  diagnosis  of  hip  disease  may  be  easy  or  difficult ;  '  in  the  earli- 
est stages  errors  in  it  are  sometimes  made,  and  care  is  necessary  for  a 
positive  diagnosis  in  any  stage.  The  most  common  error  is  the  belief 
that  the  presence  of  pain  or  tenderness  is  necessarily  present  in  hip 
disease,  and  that  its  absence  excludes  the  possibility  of  hip  disease. 
Another  error  often  made  is  to  look  for  "  grating "  in  the  joint  as  a 
sign  of  the  disease.  That  sign  is  to  be  obtained  only  by  the  use  of  an 
anaesthetic,  by  which  means  the  muscles  guarding  the  joint  are  re- 

'  R.  W.  Lovett:  "  The  Diagnosis  of  Hip  Disease."  Boston  Med.  and  Surg. 
Journ.,  August  14th,  1902. 


lOO 


ORTHOPEDIC  SURGERY. 


laxed,  and  then  only  in  advanced  cases  when  two  bony  and  eroded  sur- 
faces lie  in  contact. 

The  diagnostic  symptoms  in  hip  disease  which  should  be  borne  in 
mind  in  making  a  diagnosis  of  hip  disease  are  as  follows: 

1.  Muscular  spasm  (stiffness  of  the  joint  or  limitation  of  its  motion). 

2.  Lameness. 

3.  Attitude  of  the  limb  in  standing,  walking,  or  lying  (adduction 
flexion  and  abduction  of  the  limb),  and  shortening. 

4.  Atrophy. 

5.  Swelling. 

These  symptoms  \'ary  in  prominence  at  different  stages  of  the  dis- 
ease. 

It  may  be  said  that  the  early  diagnosis  must  be  made  chiefly  by  the 
symptom  of  muscular  rigidity  and  by  palpation  of  the  joint. _    The  ab- 


FlG.  103.— Method  of  Examining  the  Hip. 


sence  of  pain  or  sensitiveness  counts  for  nothing  and  atrophy  is  not 
significant  of  anything  more  than  inflammation  of  the  joint.  The  limp 
is  peculiar,  but  a  similar  one  is  present  in  other  conditions. 

I.  Muscular  Spasm. — The  chief  diagnostic  sign  in  hip  disease,  upon 
which  the  main  reliance  must  alwa}-s  be  placed,  is  i]ic  presence  of  stiff- 
ness of  iJie  joint  or  limitation  of  its  proper  arc  of  motion  when  the  limb 
is  passively  manipulated.  Except  in  the  very  earliest  stages  there  can 
be  no  hip  disease  without  a  perceptible  limitation  of  motion,  unless  the 
focus  of  disease  is  remote  from  the  joint.     This  limitation  of  motion  is 


TUBERCULOUS  DISEASE   OE   THE  HIP. 


lOl 


not  the  result  of  adhesions  or  beginning  ankylosis  in  early  hip  disease, 
but  it  is  the  result  of  a  tonic  contraction  of  the  muscles  controlling  the 
joint,  and  disappears  under  anaesthesia  in  the  early  stages  of  the  disease. 
In  the  detection  of  this  most  important  diagnostic  sign  it  should  be 
borne  in  mind  that  some  care  is  required  to  discover  slight  limitation  of 
motion  in  very  young  children,  who  are  apt  to  resist  thorough  examina- 
tion. The  voluntary  resistance  to  manipulation  due  to  fright  is,  how- 
ever, always  resistance  to  all  motions  of  the  limb;  if  by  slight  force  this 


Fig.  104. — Method  of  Determining  the  Limitation  of  Extension  in  Hip  Disease. 

is  overcome,  resistance  to  any  especial  motion  will  not  be  encountered 
unless  hip  disease  is  present.  A  comparison  of  the  resistance  of  one 
leg  with  that  of  the  other  will  reveal  abnormal  resistance.  The  normal 
amount  of  abduction  is,  however,  slight,  and  resistance  to  motion  in  this 
direction,  therefore,  is  an  early  test  of  importance.     Extreme  abduction 


Fig.  105.— Lordosis  Resulting  from  Bringing  the  Flexed  Leg  in  Hip  Disease    Parallel  to  the 

Other. 

and  rotation  of  the  thigh  flexed  at  right  angles  to  the  body  are  tests 
likely  to  reveal  the  smallest  degree  of  limited  motion. 

In  young  and  frightened  children  the  tests  for  limitation  of  motion 
at  the  hip-joint  are  best  made  with  the  children  lying  on  the  mother's 
lap  or  leaning  on  the  mother's  shoulder.  In  examining  older  children 
for  muscular  stiffness,  the  clothes  should  be  removed  and  the  patients 
should  lie  upon  a  hard  surface  rather  than  on  a  bed.     Attempts  to 


I02  ORTHOPEDIC  SURGERY. 

move  the  limb  should  be  made  gradually,  gently,  and  persistently- 
rough  force  only  exciting  resistance  and  making  a  delicate  examination 
impossible.  It  is  advisable  first  to  put  the  normal  leg  through  the  same 
manipulations  which  are  to  be  made  on  the  affected  side.  The  most 
convenient  order  of  motion  in  examination  is  first  flexion,  then  abduc- 
tion and  abducting  rotation  with  the  thigh  flexed,  then  extension.  The 
suspected  limb  should  be  held  at  the  ankle  or  knee  with  one  hand,  while 
the  other  hand  will  grasp  the  pelvis  to  ascertain  when  motion  in  the 
joint  ceases  and  movement  of  the  pelvis  begins.  Examination  under 
anaesthesia  shows  less  than  the  examination  mentioned,  at  the  early 
stage  of  hip  disease,  as  muscular  spasm,  the  most  important  diagnostic 
sign,  has  been  overcome  and  is  absent. 

If  the  limb  is  extended  so  that  the  popliteal  space  be  placed  upon 
the  hard  surface  on  which  the  patient  lies,  normally  there  will  be  no 
alteration  of  the  position  of  the  back;  if,  however,  there  is  a  limitation 
in  the  normal  extension  of  the  limb,  the  back  will  be  arched  up  as  the 
popliteal  space  is  pressed  down.  This  limitation  of  extension  can  also 
be  determined  by  examining  the  patient  lying  upon  the  belly.  If  one 
hand  be  placed  on  the  sacrum  and  the  thighs  be  alternately  raised  from 
the  surface  on  which  the  patient  lies,  a  difference  in  the  amount  of 
motion  at  the  hip  without  moving  the  sacrum  can  easily  be  determined. 
The  limit  to  the  amount  of  abduction  or  adduction  is  determined  by 
placing  one  hand  on  the  anterior  superior  spine  of  the  ilium  on  the 
sound  side,  and  with  the  other  hand  gently  abducting  or  adducting  the 
suspected  limb ;  when  limitation  is  present  the  pelvis,  of  course,  moves 
with  the  diseased  limb.  For  detecting  limitation  of  rotation  the  thigh 
should  be  flexed  to  a  right  angle  and  rotation  tested  in  that  position. 
The  motions  most  often  limited  in  early  hip  disease  are  abduction,  hy- 
perextension,  and  rotation  when  the  thigh  is  flexed  to  a  right  angle. 
The  loss  of  motion  in  this  group  is  always  suggestive. 

Careful  inspection  in  the  early  stages  of  hip  disease  during  manipu- 
lation will  sometimes  show  fibrillary  contraction  of  the  muscles  of  the 
thigh,  especially  the  adductors,  on  sudden  or  unexpected  movement  of 
the  limb. 

In  the  later  stages  of  hip  disease  complete  stiffness  of  the  joint  may 
be  present.  If  this  is  due  to  muscular  spasm  it  disappears,  in  a  meas- 
ure at  least,  under  complete  anaesthesia.  An  ankylosis  of  the  hip-joint 
is  as  stiff  under  full  ansesthesia  as  without  it. 

Any  catch  in  the  motion  of  the  joint  in  any  part  of  its  arc  is  exceed- 
ingly suspicious,  no  matter  how  slight  it  may  be. 

II.  Lameness. — ^At  the  earliest  stages  the  limping  may  be  intermit- 
tent and  not  constant,  and,  again,  it  may  be  so  slight  that  it  is  practi- 
cally imperceptible,  so  that  its  absence  does  not  exclude  hip  disease. 
The  diagnosis  cannot  be  made  alone  from  watching  the  child  walk. 


TUBERCULOUS  DISEASE   OF   THE  HIP. 


103 


III.  Attitudes. — Abnormal  positions  of  the  diseased  limb  at  an  early 
stage  of  the  disease  are  caused  by  the  action  of  the  muscles  holding  the 
limb  stiffly  in  a  distorted  position.  Neither  adduction  nor  abduction  of 
the  limb  is  usually  recognized  by  the  patient  as  such,  but  the  complaint 
is  made  that  the  limb  seems  longer  or  shorter  than  the  other.  The 
pelvis  is  tilted,  which  gives  a  practical  lengthening  of  the  limb  if  ab- 
duction is  present,  and  in  the  same  way  the  limb  appears  shorter  to  the 
patient  if  adducted.  The  tilting  of  the  pelvis  can  be  recognized  by 
drawing  a  line  from  the  anterior  superior  spine  of  one  side  to  that  of 
the  other.  This  should  normally  be  at  right 
angles  with  the  long  axis  of  the  body.  In  this 
way  have  arisen  the  terms  of  apparent  or  prac- 
tical shortening  and  lengthening,  which  have 
given  rise  to  some  obscurity,  being  often  con- 
fused with  real  or  bony  shortening. 

The  accompanying  diagrams  will  explain 
the  matter.  The  normal  position  of  the  pelvis 
in  relation  to  the  limbs  is  shown  in  heavy  lines 
in  Fig.  I,  where  both 
legs  are  at  right  an- 
gles to  the  pelvis,  the 
normal  position  for 
standing  and  walking. 
If,  however,  the  right 
leg  is  fixed  by  muscu- 
lar spasm  in  an  ad- 
ducted position,  A  E, 
the  relation  is  changed, 
and  when  the  patient 
stands  erect  the  legs 
must  be  made  parallel 
to  permit  walking  or 
standing  on  both  feet, 
and  this  can  be  done 
only  by  tilting  the 
pelvis  to  the  position  shown  in  Fig.  2.  It  will  be  seen  by  the  tilt- 
ing that  the  leg  A  C  is  carried  up  with  that  side  of  the  pelvis,  and 
to  all  appearances  the  leg  A  Cis  shorter  than  the  leg  B  D,  when  the 
patient  stands  or  lies  straight.  Thus  adduction  results  in  apparent 
shortening  of  the  adducted  limb  as  compared  with  the  other  when  the 
patient  lies  straight.  In  the  same  way  in  Fig.  3,  if  the  leg  A  C\s  ab- 
ducted to  the  position  A  F,  the  pelvis  must  be  tilted  in  the  opposite 
direction  to  make  the  legs  parallel,  because  the  angle  FA  ^  is  a  fixed 
quantity,  and  so  the  pelvis  is  tilted,  and  A  C  for  practical  purposes  is 


Fig  1. 
.            1 

« 

■Tl,  Z 

\ 
\ 

\ 

" 

Fig.  106.— Diagram  Showing 
Practical  Shortening  from 
Adduction. 


Fig.  107.— Diagram  Showing 
Apparent  Shortening  and 
Lengthening  of  Leg  due  to 
Tiltin"-  of  the  Pelvis. 


104  ORTHOPEDIC  SURGERY. 

longer  than  B  D,  and  the  amount  of  apparent  lengthening  depends  upon 
the  amount  of  abduction. 

A  patient  then  with  fixation  of  one  leg  in  a  position  of  adduction 
has  a  deformity  which  results  in  a  lifting  of  that  leg  from  the  ground 
when  he  stands  or  walks,  for  the  tilting  of  the  pelvis  has  caused  a  prac- 
tical shortening  of  that  leg.  In  the  same  way  abduction  causes  the 
opposite  tilting  of  the  pelvis  and  a  practical  lengthening  of  the  diseased 
leg.  So  that  the  terni  apparent  or  practical  shortening  can  be  applied 
to  the  inequality  of  the  legs  noticed  in  walking  or  standing,  which 
results  from  the  tilting  of  the  pelvis.  Practical  shortening  can  be  esti- 
mated by  measuring  from  the  umbilicus  to  each  malleolus  when  the 
patient  lies  or  stands  straight. 

Real  or  bone  sJioiiening  is  different  from  apparent  shortening.  It 
results  from  the  retarded  growth  or  atrophy  of  the  affected  limb  or 
from  the  destruction  of  bone  in  the  hip-joint.  Real  shortening  is  meas- 
ured by  a  tape  from  the  anterior  superior  spines  of  the  ilium  to  the 
malleolus  on  each  side. 

The  amount  of  enlargement  of  the  acetabulum  and  absorption  of 
the  head  of  the  femur  which  has  taken  place  may  be  estimated  by  de- 
termining the  amount  that  the  trochanter  of  the  femur  has  risen  above 
its  normal  position.  If  the  patient  lie  upon  the  well  side,  and  Nelaton's 
line  (from  the  anterior  superior  spine  to  the  most  prominent  part  of  the 
tuberosity  of  the  ischium)  be  drawn  over  the  affected  hip,  the  thigh 
being  somewhat  flexed,  it  should  pass  just  above  the  upper  margin  of 
the  trochanter ;  if  the  trochanter  is  above  this  line,  it  is  an  evidence  of 
destruction  of  part  of  the  head  of  the  femur  or  enlargement  upward  of 
the  acetabulum. 

Estimation  of  Adduction  and  Abduction. — The  amount  of  de- 
formity due  to  adduction  or  abduction  or  flexion  of  the  limb  is  an  im- 
portant index  of  the  progress  or  activity  of  the  disease  and  should  be 
carefully  estimated. 

A  simple  method  has  been  devised  by  which  it  is  possible  to  esti- 
mate with  the  tape  measure  alone  the  angle  of  either  abduction  or  ad- 
duction present. 

In  measuring  patients  it  is  found  that  real  and  practical  shortening 
of  a  leg  are  often  not  the  same  in  the  same  patient,  and  that  the  differ- 
ence between  them  varies  in  proportion  to  the  amount  of  deformity 
present.  This  was  taken  as  the  basis  for  constructing  the  following 
working  table.  The  mathematical  process  by  which  it  was  made  is 
given  in  full  in  the  original  article.'  To  measure  by  this  method,  the 
patient  is  made  to  lie  straight,  with  the  legs  parallel.  Real  shortening 
is  measured  with  the  ordinary  tape  measure,  and  apparent  shortening  is 
obtained  in  the  same  way.  It  may  be  repeated  that  real  or  bony  short 
'R.  W.  Lovett:  Bost.  Med.  and  Surg.  Journal.  March  Sth,  i8SS. 


TUBERCULOUS  DISEASE  OF   THE  HIP. 


lO: 


ening  is  measured  from  the  anterior  superior  iliac  spines  to  each  malle- 
olus, and  that  practical  shortening  is  found  by  a  measurement  taken 
from  the  umbilicus  to  each  malleolus.  The  difference  in  inches  be- 
tween the  two  kinds  of  shortening  is  seen  at  a  glance.  The  only  addi- 
tional measurement  necessary  is  the  distance  between  the  anterior 
superior  spines,  which  is  taken  with  the  tape.  Turning  now  to  the 
table,  if  the  line  which  represents  the  amount  of  difference  in  inches 
between  the  real  and  apparent  shortening  is  followed  until  it  intersects 
the  line  which  represents  the  pelvic  breadth,  the  angle  of  deformity  will 
be  found  in  degrees,  where  they  meet.  If  the  practical  sJioTtcning  is 
greater  than  the  real  shortening,  the  diseased  leg  is  adducted ;  if  less 
than  real  shortening,  it  is  abducted.  Take  an  example :  Length  (from 
anterior  superior  spine)  of  right  leg,  23;  left  leg,  22^;  length  (from 
umbilicus)  of  right  leg,  25 ;  left  leg,  23 ;  real  shortening  %  an  inch, 
apparent  shortening  2  inches;  difference  between  real  and  practical 
shortening,  ly^  inches;  pelvic  measurement,  7  inches.  If  we  follow 
the  line  for  i^  inches  until  it  intersects  the  line  for  pelvic  breadth  of 
7  inches,  we  find  12°  to  be  the  angular  deformity;  as  the  practical 
shortening  is  greater  than  the  real,  it  is  12°  of  adduction  of  the  left  leg. 
If  apparent  lengthening  is  present  its  amount  should  be  added  to  the 
amount  of  actual  shortening. 

Table  I. 
Distance  between  Anterior  Superior  Spines  in  inches. 


bi) 

'A 

H 

I 

2 

2% 
3 

3X 
Z% 

iX 

4 

3 

3  J 

^  4 

4/2 

5 

S'A    6 

ey 

7 

7>2 

8 

8>^ 

9 

9>^ 

10 

II 

12 

13 

5^ 

4' 

4' 

3 

3° 

aj 

2=    2 

2^ 

2° 

2'" 

2° 

2° 

2° 

1° 

i"' 

1° 

1' 

i" 

0 

10 

8 

7 

6 

5 

5       4 

4 

4 

4 

4 

4 

4 

3 

3 

3 

3 

2 

■Ji 

14 

12 

II 

10 

8 

8   7 

7 

6 

6 

5 

5 

5 

4 

4 

4 

3 

3 

<u 

< 

19 

17 

14 

13 

II 

10   9 

9 

8 

7 

7 

7 

6 

6 

6 

5 

5 

4 

25 

21 

18 

16 

14 
17 

13   12 

II 

10 

9 

9 

8 

8 

7 

7 

7 

6 

6 

XJ 

30 

25 

22 

19 

15   M 

13 

12 

12 

II 

10 

10 

9 

9 

8 

7 

7 

H 

36 

30 

26 

23 

20 

iS   17 

15 

14 

13 

13 

12 

II 

10 

10 

9 

8 

8 

ry 

42 

35 

30 

26 

23 

21   19 

18 

16 

15 

14 

14 

13 

12 

12 

10 

10 

9 

ID 

.0 

40 

34 

IP 

26 

24  21 

20 

19 

17 

16 

15 

14 

14 

13 

12 

II 

10 

39 

34 

29 

27  24 

22 

21 

19 

18 

17 

16 

15 

14 

13 

12 

II 

(L> 

38 

32 

29  27 

25 

23 

21 

20 

19 

18 

17 

16 

14 

13 

12 

U 

42 

35 

32   29 

27 

-5 

23 

22 

21 

19 

18 

iS 

16 

14 

13 

39 

36  32 

30 

27 

26 

25 

■^2 

21 

20 

19 

17 

15 

14 

40  35 

33 

30 

28 

26 

24 

23 

22 

21 

19 

17 

16 

<u 

..   38 

35 

32 

30 

28 

26 

25 

23 

22 

20 

iS 

17 

Q 

..   42 

38 

35 

32 

30 

28 

26 

25 

23 

21 

19 

iS 

io6 


ORTHOPEDIC  SURGERY. 


Estimation  of  Flexion. — The  flexion  deformity  of  the  thigh  may 
be  measured  by  a  similar  method/  The  patient  lies  upon  a  table  flat 
on  his  back  and  the  surgeon  flexes  the  diseased  leg,  raising  it  by  the 
foot  until  the  lumbar  vertebrae  touch  the  table,  showing  that  the  pelvis 
is  in  the  correct  position.  The  leg  is  then  held  for  a  minute  at  that 
angle,  the  knee  being  extended,  while  the  surgeon  measures  off  two 
feet  on  the  outside  of  the  leg  with  a  tape  measure,  one  end  of  which 


Fig.  ioS.— Estimation  of  Flexion. 

is  held  on  the  table  (so  that  the  tape  measure  follows  the  line  of  the 
leg)  (^A  B).  From  this  point  on  the  leg  (B)  where  the  measurement 
of  two  feet  ends,  one  measures  perpendicularly  to  the  table  {B,  C), 
and  the  number  of  inches  in  the  line  B  6' can  be  read  as  degrees  of  flex- 
ion of  the  thigh,  by  consulting  Table  II.  For  instance,  if  the  distance 
between  the  point  on  the  leg  and  the  table  is  I2>i^  inches,  it  represents 
31°  of  flexion  deformity  of  the  thigh. 

Table  II. 


In. 

Deg. 

In. 

Deg. 

In. 

Deg. 

In. 

Deg. 

0-5 

I 

6.5 

16 

12.5 

31 

1S.5 

50 

I.O 

2 

7.0 

17 

13.0 

2)2i 

19.0 

52 

1.5 

3 

7-5 

19 

13-5 

34 

19-5 

54 

2.0 

4 

8.0 

20 

14.0 

36 

20.0 

56 

2-5 

6 

8.5 

21 

14-5 

37 

20.5 

58 

3-0 

7 

9.0 

22 

15.0 

39 

21.0 

60 

3-5 

9 

9-5 

24 

15-5 

40 

21.5 

63 

4.0 

10 

10. 0 

25 

16.0 

42 

22.0 

67 

4-5 

II 

10.5 

27 

16.S 

43 

22.5 

70 

5-0 

12 

II. 0 

28 

17.0 

45 

23.0 

75 

5-5 

14 

"■5 

29 

'7-5 

47 

23-5 

80 

6.0 

15 

12.0 

39 

18.0 

48 

24.0 

90 

If  the  leg  is  so  short  that  it  is  impracticable  to  measure  off  twenty- 
four  inches,  one  can  measure  twelve  inches ;  ascertain  from  here  the 
1  G.  L.  Kingsley  :  Bost.  Med.  and  Surg.  Jour.,  July  5th,  1S88. 


TUBERCULOUS  DISEASE   OF   THE  HIP. 


107 


distance  to  the  surface  on  which  the  patient  is  lying  in  a  ]:)erpendicular 
hne  in  the  same  way,  then  doubhng  this  distance  and  looking-  in  the 
table  as  before,  the  amount  of  flexion  is  found. 

Thomas'  test  for  flexion  is  one  which  is  sometimes  of  use  for  a  rough 
estimation  of  the  amount  of  flexion  deformity.  The  patient  lies  on  the 
back  and  the  well  thigh  is  flexed  on  to  the  abdomen  and  held  there. 
This  places  the  pelvis  in  the  correct  position,  with  the  lumbar  spine  in 
contact  with  the  table,  and  the  diseased  thigh  is  by  this  naturally 


Fig.  109.— Thomas'  Test  for  the  Estimation  of  Flexion  of  the  Diseased  Leg  in  Hip  Disease. 


thrown  into  a  position  of  flexion  if  such  deformity  exists.  It  is  not 
suitable  for  use  in  cases  in  which  the  hip  is  sensitive,  nor,  as  a  rule,  in 
the  case  of  adults. 

IV.  Atrophy. — Atrophy  is  a  symptom  of  great  significance.  Its 
absence  in  real  hip  disease  is  most  unusual,  its  presence  suggestive 
but  not  diagnostic,  for  it  exists  in  acute  joint  inflammation  of  any 
type. 

The  measurement  for  atrophy  is  made  with  a  tape  measure  by  tak- 
ing the  circumference  of  both  thighs  and  both  calves  at  the  same  level 
on  each  side.  The  conventional  places  for  such  measurements  are  at 
the  middle  of  the  thigh  and  the  middle  of  the  calf. 

V.  Swelling. — The  existence  of  deep  thickening  over  the  front  of 
the  hip-joint  or  behind  the  trochanter  is  of  great  significance,  and  of 
the  signs  mentioned  is  the  one  least  likely  to  be  present  in  cases  simu- 
lating tuberculous  hip  disease.  It  is  not  easily  recognized.  Thicken- 
ing of  the  trochanter  major  is  a  diagnostic  sign  of  assistance. 

Pain. — The  significance  of  pain  has  been  mentioned.  "  Night 
cries  "  characteristic  of  hip  disease  have  already  been  mentioned ;  they 
are  extremely  significant  in  pointing  to  the  probable  existence  of  seri- 
ous joint  disease,  but  they  may  exist  in  cases  which  do  not  prove  to  be 
real  hip  disease.     It  is  no  sign  of  the  absence  of  hip  disease  when  one 


I08 


ORTHOPEDIC  SURGERY 


is  able  suddenly  to  jam  the  head  of  the  femur  into  the  acetabulum 
without  causing  pain — a  diagnostic  method  sometimes  relied  on.  Its 
violence  makes  it  unjustifiable  as  well  as  untrustworthy. 


DIFFERENTIAL   DIAGNOSIS. 


Some  affections  commonly  mistaken  for  tuberculous  hip  disease  in 
practice  desen.'e  notice. 

I.  Synovitis  of  the  hip,  jf  traumatic,  infectious,  or  rheumatic  ori- 
gin, or  from  no  assignable  cause,  may  occur  in  children,  but  it  presents 


Fig.  no.  —  JS'-Ra— .    Femoral  disease.    Slight  atrophy  of  femur  and  pubic  borse. 
head  of  fenmr.     Thickening  of  neck  of  femur. 


Ercsion  of 


the  symptoms  of  beginning  hip  disease  and  a  diagnosis  is  iwi  practica- 
ble in  the  earl}-  stages ;  the  fact  that  the  svmptoms  occur  after  a  fall 
must  not  be  allowed  too  much  weight  as  arguing  in  favor  of  synovitis. 

It  is  distinguishable  from  true  hip  disease  only  by  its  relatively 
briefer  course.  In  s}Tiovitis  the  usual  joint  s\-mptoms,  such  as  atro- 
phy, muscular  spasm,  night  cries,  etc.,  ma}-  be  present.' 

Marked  thickening  about  the  joint  is  less  noticeable  in  the  early 
stages  than  in  hip  disease. 

'Boston  ^led.  and  Sur^^.  Journal.  cxsAii. .  i6i. 


TUBERCULOUS  D  IS  EASE   OF    THE  J I  IP.  109 

In  adults,  synovitis  of  the  hip  may  come  on  ciearl}' after  a  fall; 
there  is  no  history  of  preceding"  disability,  and  muscular  spasm  and 
wasting'  are  present. 

2.  Lumbar  Pott's  disease  ma)'  have  for  its  first  symptom  a  limp 
and  a  restriction  of  motion  in  one  leg.  This  is  due  to  the  descent  of 
pus  in  the  psoas  muscle  or  to  an  irritation  and  contraction  of  its  fibres. 
As  a  rule,  this  limited  motion  is  only  in  the  direction  of  loss  of  hyper- 
e.xtension,  but  it  may  take  occasionally  the  form  of  a  general  restriction 
of  motion  and  the  joint  may  be  sensitive  to  manipulation.  The  point 
to  be  determined  is  whether  rigidity  of  the  lumbar  spine  is  present; 
if  so,  Pott's  disease  is  to  be  suspected,  l^ut  sometimes  in  hip  disease  at 
a  sensitive  stage  the  tenderness  of  the  joint  is  so  great  that  on  at- 
tempted fle.xion  of  the  spine  the  erector  spin?e  muscles  are  also  spas- 
modically contracted  and  lead  to  the  appearance  of  rigidity  of  the  lum- 
bar spine.  The  diagnosis  may  sometimes  be  a  very  difficult  one,  and 
an  opinion  must  be  withheld  and  the  case  kept  under  observation  until 
characteristic  symptoms  of  one  affection  or  the  other  develop.  Later 
in  the  histor)'  oi  lumbar  Pott's  disease  a  psoas  abscess  will  often  de- 
scend and  may  irritate  the  hip-joint  on  one  or  both  sides;  this  may 
again  so  closely  simulate  hip  disease  that  it  is  hard  to  tell  whether  the 
psoas  muscle  is  causing  all  the  trouble  or  whether  the  hip-joint  is  really 
involved.  A  test  of  the  arc  of  abduction  of  the  hip  may  be  valuable 
in  this  connection,  as  this  motion  is  impaired  or  lost  at  a  comparatively 
early  stage  of  hip  disease.  It  is  an  excellent  rule  never  to  make  a  diag- 
nosis of  hip  disease  without  examining  the  spine  to  see  if  Pott's  disease 
is  present. 

3.  Chronic  arthritis  deformans,  morbus  coxae  senilis,  which  in  many 
cases  remains  purely  a  synovitis  without  ostitis,  begins  sometimes  idio- 
pathically  without  the  history  of  even  slight  injury.  A  diagnostic 
point  relates  always  to  the  age  at  which  the  patient  is  attacked,  it  being- 
much  less  common  in  childhood,  except  in  extensive  cases  in  which 
other  joints  are  affected.  The  presence  of  arthritis  may,  of  course,  be 
demonstrated  in  other  joints.  The  .I'-ray  is  of  value  in  showing  bone 
proliferation. 

4.  Acute  Infectious  Inflammation  (Osteomyelitis)  of  the  Hip  Joint. — 
The  S3-mptoms  are  more  acute  than  in  hip  disease,  the  swelling  is 
greater,  and  the  temperature  higher  as  a  rule.  In  young  children 
the  diagnosis  is  often  obscure  until  operation  is  rec^uired  by  abscess. 
In  Konig's  collection  of  758  cases  of  hip-joint  inflammation  there  were 
568  tuberculous  cases  and  no  of  acute  infectious  coxitis.' 

5.  Anterior  Poliomyelitis. — At  the  stage  of  onset  of  infantile  par- 
alysis there  may  be  for  a  short  time,  in  rare  instances,  marked  pain  and 
tenderness,  with  immobility  of  one  limb ;    ordinarily  these  s}-mptoms 

'  Konig- :  "Die  spec.  Tub.  d.  Knochen  und  Gelenke,"  pt.  ii.,  p.  123. 


no  ORTHOPEDIC  SURGERY. 

are  not  accompanied  by  other  symptoms  of  hip  disease,  but  are  ac- 
companied by  loss  of  power  of  the  rest  of  the  hmb  as  well  as  a  loss  of 
its  normal  warmth,  rapidly  followed  by  atrophy  in  the  whole  limb.  In 
the  late  stages  of  infantile  paralysis  there  is  no  stiffness  at  the  hip- 
joint,  but  we  note  abnormal  mobility  in  all  directions  and  other  evi- 
dences of  infantile  paralysis,  such  as  distortion  of  the  foot  and  knee, 
coldness,  atrophy,  and  marked  loss  of  power  of  certain  muscular  groups 
which  make  an  error  in  diagnosis  very  unlikely. 

6.  Congenital  Dislocation. — Congenital  dislocation  of  the  hip-joint 
need  not  be  mistaken  for  hip  disease,  as  the  clinical  history  of  the 
former  is  of  continued  limp  since  the  child  commenced  walking.  The 
trochanter  is  above  Nelaton's  line.  There  are  no  symptoms  of  muscu- 
lar stiffness  or  limitation  of  motion  of  the  hip  in  congenital  dislocation ; 
in  fact,  no  symptoms  of  hip  disease  except  the  limp  in  gait.  Patients 
with  congenital  dislocation,  however,  at  times  have  slight  attacks  of 
synovitis  of  the  hip  due  to  the  imperfect  mechanism  of  the  joint,  but 
these  symptoms  subside  after  a  short  rest. 

7.  Hysterical  joint  affections,  as  they  are  to  be  diagnosticated 
from  organic  joint  disease,  will  be  considered  more  fully  under  the 
head  of  functional  joint  disease.  It  may  be  said  here  that  the  symp- 
toms of  functional  and  organic  hip  disease  may  be  much  the  same,  the 
characteristic  of  the  former  being  that  they  are  variable  in  their  inten- 
sity and  not  consistent  with  one  another. 

8.  Coxa  vara,  a  distortion  of  the  neck  of  the  femur,  gives  rise 
to  shortening  and  limping.  The  trochanter  is  higher  than  Nela- 
ton's line.  There  is  either  good  motion  at  the  hip-joint  or  the  limita- 
tion is  in  the  direction  of  abduction,  while  the  flexion  is  free.  The 
amount  of  limitation  of  motion  is  less  than  would  be  expected  from  the 
history  of  the  case,  which  is  of  long  duration.  The  diagnosis  is  aided  . 
by  a  skiagram. 

9.  Knee-joint  Disease.  — Hip  disease  is  often  diagnosticated  as 
"knee  trouble,"  so  that  it  seems  worth  while  to  call  attention  to  the 
well-known  fact  that  pain  in  hip  disease  is  in  most  cases  referred  to  the 
inner  side  of  the  knee.  Examination  will  show  which  affection  is 
present. 

10.  Miscellaneous  Conditions.— Perinephritis  and  appendicitis 
have  been  mistaken  for  hip  disease.  Such  an  error,  however,  must  be 
rare.  In  the  chronic  forms  of  these  affections  there  may  be  slight 
psoas  contractions  and  the  presence  of  iliac  abscesses.  In  these  affec- 
tions the  limitation  to  motion  of  the  thigh  at  the  hip-joint  is  not  general 
nor  does  it  affect  abduction,  but  it  is  most  marked  in  the  direction  of 
limitation  of  extension. 

Periarticular  disease,  which  has  not  yet  attacked  the  joint  or 
the  epiphyses  of  the  joint,  is  recognized  with  difficulty.     Under  the 


TUBERCULOUS  DISEASE  OF  THE  HIP.  in 

head  of  periarticular  disease  may  be  included  inflammation  of  bursas 
and  lymphatic  glands,  psoas  abscess,  or  psoas  muscular  spasm  from 
caries  of  the  lumbar  spine  (psoitis). 

Sarcoma  of  the  hip  may  be  mistaken  for  hip  disease  or  hip  dis- 
ease for  sarcoma.  The  ,r-ray  may  give  assistance  in  the  diagnosis  and 
a  piece  of  the  growth  should,  of  course,  be  removed  for  examination. 

Separation  of  the  Epiphysis  of  the  Femur. — Separation  of 
the  epiphysis  or  fracture  of  the  neck  of  the  femur,  with  the  resulting 
distortion,  which  may  be  termed  traumatic  coxa  vara,  can  be  distin- 
guished from  hip  disease  by  the  history  aided  by  an  .^'-ray  examination. 

PROGNOSIS. 

Under  favorable  surroundings  the  disease  is  one  which  tends  to 
recovery  in  a  majority  of  cases  with  more  or  less  deformity.  It  is  the 
duty  of  the  surgeon  to  see  that  the  chances  of  recovery  are  as  favorable 
as  possible,  and  when  recovery  occurs  that  it  shall  result  with  the  least 
deformity  and  the  most  useful  limb  possible. 

Mortality. — The  rate  of  the  mortality  due  to  the  disease  in  hip  dis- 
ease is  greater  among  the  poorly  nurtured  hospital  cases  than  where 
after-treatment  can  be  carefully  looked  after. 

Cazin '  reported,  in  80  cases  of  suppurative  hip  disease  treated  at 
the  hospital  at  Berck,  in  the  course  of  five  years,  55  per  cent  were 
cured;  12.5  per  cent  died;  25  per  cent  were  not  cured;  7.5  per  cent 
were  improved  when  removed.  Of  288  cases  collected  by  Gibney 
there  was  a  mortality  of  12.5  per  cent  from  exhaustion,  meningitis,  and 
amyloid  degeneration.  In  the  Alexandra  Hospital,  London,  there  were 
100  deaths  out  of  384,  a  mortality  of  26  per  cent;  of  these,  260  were 
suppurating  cases,  and  the  death  rate  of  these  was  33.5  per  cent. 
Forty-two  per  cent  were  reported  cured.  C.  F.  Taylor,  of  New  York, 
has  reported  94  cases  in  private  practice,  with  only  3  deaths ;  of  these 
94,  24  were  suppurating.  Hueter  reports  the  mortality  of  hospital 
cases  at  27  per  cent,  and  Billroth  at  31  per  cent.  Jacobson  reported  a 
mortality  rate  of  73.2  per  cent  in  63  suppurating  cases.  The  mortality 
rate  from  the  disease  alone  has  been  generally  considered  to  be  about  30 
per  cent.  Shaffer  and  Lovett  investigated  51  cases  of  cured  hip  disease 
which  had  been  discharged  from  the  New  York  Orthopedic  Dispensary 
at  least  four  years  previously,  and  found  that  41  had  remained  cured. 
Of  the  remaining  10,  4  had  died  and  6  had  relapsed,  although  4  of  the 
latter  had  been  apparently  cured  a  second  time.'" 

Causes  of  Death. — ^Death  may  occur  from  (i)  the  generalization  of 
tuberculosis  in  the  form  of  phthisis,  tuberculous  meningitis,  and  gen- 

' "  Statistique  des  Coxalgies  suppures,"  Bull,  de  la  Soc.  de  Chirurgie,  No.  5, 
1S76.— Shaffer  and  Lovett:  N.  Y.  Med.  Journ.,  May  21st,  1SS7. 
■N.  Y.  Medical  Journal,  May  21st,  1S87. 


I  12 


ORTHOPEDIC  SURGERY 


eral  tuberculosis ;  (2)  from  amyloid  degeneration  of  the  viscera;  (3) 
from  exhaustion;  (4)  from  intercurrent  disease;  (5)  from  septicaemia 
and  exhaustion  after  suppuration. 

Functional  Results. — Spontaneous  cure  may  result  in  hip  disease, 
but  as  a  rule  with  little  motion  and  with  marked  deformity.' 

Recovery  with  complete  motion  after  tuberculous  hip  disease  is 
rare,  but  occurs  even  in  hospital  cases.  From  this  condition  to  com- 
plete loss  of  motion  the  cases  range  according  to  the  thoroughness  of 
treatment,  the  severity  of  the  disease  in  the  individual  case,  and  the 
resistance  of  the  child.     The  earlier  that  treatment  is  begun  the  better 


Fig.  III.  Fig.  112. 

Figs,   m  and  112.— A  Case  of  Hip  Disease  under  Ambulatory  Treatment.      Result  .s:ood. 
Motion  to  right  angle.     CChildren's  Hospital  Report.) 

the  outlook.  A  cure  by  ankylosis  would  be  expected  by  the  writers  in 
perhaps  a  quarter  or  a  third  of  hospital  cases  who  followed  out  treat- 
ment properly.  Some  amount  of  motion  would  be  expected  in  the 
majority  of  cases.  The  amount  of  joint  motion  is  likely  to  diminish 
rather  than  increase  in  the  years  following  treatment. 

The  prognosis  in  hip  disease  in  adults  is  less  favorable  than  in  chil- 
dren, as  the  process  is  generally  of  a  severer  type. 

'New  York  Med.  Rec.  I\Iarch  2d.  1S7S.— Trans.  Am.  Orth.  Assn.,  vol.  xi.,  p. 
256. 


TUBERCULOUS  DISEASE   OF   THE  HIP. 


113 


If  a  cure  with  ankylosis  takes  place,  an  important  practical  point, 
as  regards  the  use  of  the  limb  and  locomotion,  is  the  position  in  which 
ankylosis  occurs.' 

Length  of  Time  for  Treatment. — It  may  be  stated  that  at  least  from 


two  to  three  years  will  probably  be 
needed  in  the  treatment  of  a  case 
of  hip  disease  taken  at  an  early  stage, 
while  protection  to  the  joint  will  be  ad- 
visable for  two  or  three  years  more. 
The  early  discontinuance  of  treatment  is  a  serious  mistake,  as  re- 
'N.  Y.  Med.  Record,  March  2d,  1878.— British  Med.  Journ.,  August  3d,  1889. 


Fig.  113.— End  Result  in  Patient  with 
Hip  Disease  under  Traction  Treat- 
ment. Traction  two  and  one-half 
years.  Trochanter  on  Nelaton's 
line  (see  Fig.  114). 


114 


ORTHOPEDIC  SURGERY. 


lapses  are  likely  to  occur  when  everything  seems  quiet.  In  the  same 
way  too  early  a  discontinuance  of  the  convalescent  splint  will  often 
cause  trouble.  It  is  therefore  much  safer  to  err  on  the  side  of  keeping 
on  an  apparatus  unnecessarily  long  than  to  run  what  would  seem  to  be 
a  considerable  risk  of  relapse.     Even  when  a  relapse  does  not  occur, 

the  too  early  discontinuance  of 
treatment  may  lead  to  an  in- 
crease in  the  flexion  or  adduction 
deformity. 

Distortion The  prognosis  as 

to  distortion,  however,  does  not 
necessarily  imply  permanent  dis- 
tortion ;  for  at  the  present  time, 
after  recovery  from  hip  disease 
(the  deformity  still  existing  with 
severe  flexion  and  adduction) 
these  disfigurements  can  be  en- 
tirely and  permanently  relieved 
by  subtrochanteric  osteotomy. 
It  is,  however,  much  more  desir- 
able to  correct  malposition  of  the 
limb  whenever  it  occurs  than  to 
allow  it  to  become  permanent, 
when  its  correction  is  a  much 
more  serious  matter.  The  prog- 
nosis as  to  lameness  will  depend 
on  the  amount  of  malposition  of 
the  limb,  the  amount  of  motion 
present,  and  the  degree  of  short- 
ening. 

Shortening. — Some  shorten- 
ing will  be  present  in  a  majority 
of  cases  if  the  disease  continues 
for  any  time,  but  for  practical  use 
in  locomotion  the  actual  shortening  is  of  much  less  moment  than  the 
position  of  the  limb.  At  the  close  of  the  disease  an  average  amount  of 
shortening  would  be  from  half  an  inch  to  two  inches,  if  one  considered 
the  severer  cases.  There  may  be  no  shortening,  but  if  the  head  of  the 
femur  is  dislocated  it  may  be  a  shortening  of  from  three  to  five  inches. 
Actual  shortening  due. to  arrest  of  growth  of  the  limb  is  beyond  the 
control  of  the  surgeon;  but  shortening  from  subluxation  or  dislocation 
of  the  head  of  the  femur  or  enlargement  of  the  acetabulum  may  be  said 
to  be  due  to  a  lack  of  thoroughness  of  treatment  by  traction.  Perfect 
treatment  may  in  some  instances  be  impossible,  from  circumstances 


Fig.  115. — Cured  Case  with  Marked  Permanent 
Flexion,  showini?  Lumbar  Lordosis. 


TUBERCULOUS  DISEASE   OF   THE  HIP.  115 

beyond  the  control  of  the  surgeon;  but  he  should  persistently  bear  in 
mind  that  subluxation  and  distortion  from  that  source  can  be  prevented 
by  thorough  treatment  of  the  disease. 

Atrophy  is  never  entirely  cured  in  severe  cases,  but  in  the  calf  mus- 
cles it  diminishes  very  much  after  the  use  of  the  leg  is  resumed. 

Abscess. — The  significance  of  abscess  is  not  very  great;  it  does  not 
affect  the  ultimate  amount  of  motion  in  the  joint  nor  does  it  seriously 
increase  the  shortening.' 

When  abscesses  occur  in  cases  under  careful  mechanical  treatment, 
the  outlook  is  worse  than  in  suppurative  hip  disease  in  general,  because 
the  careful  treatment  prevents  the  occurrence  of  abscess  in  all  but  the 
W()rst  cases,  so  that  in  these  the  death  rate  is  necessarily  high.  In  a 
series  of  63  cases  of  abscess  from  the  Boston  Children's  Hospital,-  the 
death  rate  was  40  per  cent.  Abscess  occurred  in  18.7  per  cent  of  574 
cases  of  hip  disease  under  out-patient  treatment  which  were  analyzed.^ 

The  amount  of  sensitiveness  of  the  hip  and  pain  in  cases  which  are 
well  treated  should  be  slight,  though  nocturnal  cries  may  persist  for  a 
while  in  the  early  stages.  The  reoccurrence  of  night  cries  late  in  the 
disease,  or  of  acute  sensitiveness  of  the  joint,  is  most  often  a  sign  of 
inadequate  treatment  or  of  trouble  coming  in  the  joint;  most  frequently 
it  precedes  the  occurrence  of  abscess. 

Under  conservative  treatment  carried  out  for  a  sufficient  time  one 
may  expect  a  good  functional  result  in  the  majority  of  cases.  In  few 
diseases  is  the  benefit  of  thorough,  skilled,  and  long-continued  treat- 
ment more  clear,  and  in  few  surgical  affections  can  the  surgeon  attempt 
to  check  the  progress  of  disease  and  influence  recovery  with  greater 
probability  of  success  than  in  hip  disease ;  but  the  surgical  care  and 
supervision  should  not  be  limited  to  the  more  acute  stages  of  the  affec- 
tion, but  should  be  continued  during  the  convalescent  stage  if  the  best 
results  are  desired.' 

TREATMENT. 

General  Considerations  Influencing  Treatment, 

It  is  to  be  remembered  that  the  hip-joint  differs  from  the  other 
joints  in  that  it  is  surrounded  by  strong  muscles.  These,  in  case  of 
acute  inflammation  of  the  joint,  develop  a  condition  of  exaggerated  irri- 
tability analogous  to  the  blepharospasm  in  ulceration  of  the  cornea. 
This  condition  needs  surgical  consideration,  as  unless  checked  it  will 

'  Shaffer  and  Lovett :  Loc.  cit. 

'^Boston  Med.  and  Surg.  Journ.,  November  21st,  1SS9,  p.  503. 

^  Lovett :  "  Dis.  of  Hip,"  p.  1 17. 

•*The  report  of  certain  representative  cases,  with  the  results  obtained  in  them, 
will  be  found  in  the  second  edition  of  this  book,  p.  241.  They  are  omitted  in  the 
present  edition  as  unnecessary. 


Ii6  ORTHOPEDIC  SURGERY. 

develop  deformity  and  destruction  of  the  joint.  The  means  at  the  sur- 
geon's disposal  besides  operative  measures  may  be  classed  as  means  of 
fixing  the  joint,  distracting  the  joint,  and  protecting  it  from  injury,  and 
involve  a  consideration  of  methods  of  (i)  fixation,  (2)  traction,  (3;  pro- 
tection. 

The  treatment  of  tuberculous  ostitis  of  the  hip-joint  is  based  upon 
the  same  principles  that  are  of  importance  in  the  treatment  of  tuber- 
culous ostitis  of  other  joints,  modified  by  the  special  anatomical  condi- 
tions of  the  hip. 

The  Principles  of  Treatment  by  Fixation  and  Traction. 

The  object  of  fixing  any  joint  affected  with  ostitis  is  to  prevent  an 
aggravation  of  the  inflammation  of  the  bone  by  the  injury  incident  to 
motion.  In  an  acutely  inflamed  condition  the  slightest  motion  involves 
joint  injury  and  is  to  be  avoided  while  the  acute  stage  persists.  In 
many  joints  it  is  necessary  merely  to  secure  firmly  the  bones  forming 
the  joint,  and  injury  to  the  joint  is  prevented.  In  the  hip-joint,  hov/- 
ever,  two  factors  militate  against  the  efficiency  of  the  ordinary  methods 
of  fixation : 

1.  The  difficulty  met  in  securing  the  upper  portion  of  the  joint,  viz., 
the  pelvis,  which,  owing  to  the  mobility  of  the  lumbar  vertebrae,  is  not 
secured  by  fixing  the  trunk. 

2.  The  muscular  spasm  of  the  strong  muscles  about  the  hip-joint. 
These  muscles  are  in  hip-joint  inflammation  in  a  state  of  reflex  irrita- 
bility or  of  tonic  spasm,  and  either  crowd  the  head  of  the  femur  against 
the  acetabulum  by  a  continued  muscular  contraction  or  inflict  upon 
the  joint  the  injury  of  a  sudden  muscular  contraction  of  all  the 
muscles  around  the  hip.  The  amount  of  this  injury  can  be  easily  es- 
timated in  even  the  weakest  of  children  by  an  examination  of  a  cross- 
section  of  the  muscles.  Adults  who  have  experienced  these  attacks  of 
muscular  spasm  liken  the  sensation  to  that  of  a  blow  of  a  sledge-ham- 
mer upon  the  hip. 

The  importance  in  the  treatment  of  hip  disease  of  this  increased  ar- 
ticular pressure  is  shown  by  pathological  evidence,  which  demonstrates 
the  destruction  of  the  bones  forming  the  joint  in  the  direction  of  such 
pressure  and  the  absence  or  diminution  of  such  destruction  where  this 
exaggerated  pressure  has  been  diminished. 

The  effects  of  traction,  when  thoroughly  carried  out,  can  be  seen  in 
the  specimens  shown  in  the  figures. 

A  comparison  of  such  specimens  with  those  of  severe  hip  disease  in 
which  traction  was  not  used  speaks  most  emphatically  for  the  thorough 
use  of  the  method. 

But  although  these  facts  have  been  recognized,  there  has  been  a 
lack  of  exact  knowledge  of  the  amount  of  force  necessary  to  counteract 


TUBERCULOUS  DISEASE   OF   THE  HIP.  117 

ex:^gge rated  intraarticular  pressure  and  when  to  apply  it.  To  deter- 
mine this,  a  series  of  investigations  were  made  by  the  writers,'  which 
demonstrated  that  in  healthy  joints  an  appreciable  amount  of  distrac- 
tion was  possible  in  children  by  a  traction  force  of  twenty  pounds ;  but 
in  certain  cases  this  distraction  did  not  take  place  immediately  on  the 
application  of  the  traction  force,  which  served  at  first  as  a  stimulant  to 
the  muscles.  In  children  suffering  from  hip  disease  in  the  chronic  sup- 
purative stage,  with  disorganization  of  the  articular  ligaments,  a  trac- 
tion force  of  ten  pounds  caused  distraction.  In  the  late  stage  of  hip 
disease,  when  the  cicatricial  contraction  of  the  capsule  and  tissues  has 
taken  place,  distraction  is  not  effected  by  a  traction  force.  In  suppu- 
rative cases  of  hip  disease  with  extensive  disorganization  of  the  cotyloid 
ligament,  a  slight  traction  force  of  a  few  pounds  causes  distraction. 
This  can  be  easily  demonstrated  when  a  joint  disorganized  by  hip  dis- 
ease is  cut  down  upon  and  the  finger  inserted  into  the  joint.  Although 
under  attempts  at  fixation  of  the  hip-joint  without  traction  the  violence 
of  the  spasm  of  the  muscles  of  the  hip-joint  diminishes,  it  is  impossible 
to  prevent  entirely  injurious  muscular  spasm  without  traction,  and  it 
will  also  be  found  that  cases  treated  by  so-called  fixation  alone  will 
mean  a  greater  danger  of  pressure  destruction  of  the  head  of  the  femur 
and  wandering  of  the  acetabulum  than  when  traction  is  efficiently  ap- 
plied. 

It  would  appear  that  no  thorough  fixation  of  the  inflamed  hip-joint 
is  possible  without  traction,  and  that  when  a  patient  is  suffering  from 
an  acute  condition  of  tuberculous  ostitis  to  such  an  extent  that  all  mo- 
tion is  injurious,  it  is  also  necessary  to  provide  for  protection  of  the 
joint  from  injurious  muscular  spasm. 

The  consideration  of  the  treatment  of  hip  disease  for  practical  pur- 
poses may  be  divided  into :  A,  The  treatment  of  the  acute  stage ;  B,  the 
treatment  of  the  subacute  stage ;  and  C,  the  treatment  of  the  conva- 
lescent stage. 

A.  The  Treatment  of  the  Acute  Stage. — Treatment  at  this  stage 
demands  arrangements  which  will  prevent  movement  of  the  joints  and 
pressure  from  muscular  spasm.  To  prevent  movement  of  the  hip-joint, 
the  ordinary  gas-pipe  bed-frame  (Chapter  XXI.,  9)  already  described 
will  be  found  of  practical  value.  The  child  is  placed  upon  the  back 
upon  this  frame,  and  the  shoulders,  pelvis,  and  unaffected  leg  are  se- 
cured by  means  of  straps.  Traction  is  then  applied  to  the  length  of  the 
leg  by  a  pulley  attached  to  the  foot  of  the  bed.  This  pulley  is  arranged 
in  such  a  way  that  it  pulls  upon  the  diseased  leg  in  the  line  in  which  it 
is  held  when  the  pelvis  is  placed  square  upon  the  frame.  If  flexion  is 
present  the  pulley  is  elevated,  and  if  adduction  or  abduction  is  present 
the  leg  is  pulled  in  or  out.  If  the  leg  is  pulled  in  a  position  of  flexion, 
'  Children's  Hospital  Report,  1S9S. 


ii8 


ORTHOPEDIC  SURGERY. 


it  is  held  irx  position  by  an  inclined  plane  or  by  folded  sheets  placed 
under  it.  The  amount  of  traction  force  to  be  used  is  a  question  of 
judgment  in  each  case,  but  as  much  weight  should  be  applied  as  can  be 
borne  without  discomfort  by  the  patient.  The  foot  of  the  bed  should 
be  raised  to  furnish  counter-traction.  If  the  patient  is  too  sensitive  to 
be  placed  upon  the  bed-pan  without  discomfort,  a  hole  should  be  cut 


Fig.  ii6. — Method  of  vSecuring  Child  to  Bed  Frame  for  Recumbent  Treatment  of  Hip  Disease 

without  Deformit5'. 

in  the  covering  of  the  frame  to  allow  the  bed-pan  to  be  placed  under 
the  frame  without  disturbing  the  patient.  The  patient  should  be 
turned  once  a  day  to  have  the  back  rubbed  with  alcohol,  and  this  should 
be  done  with  extreme  care.     Traction  should  be  made  upon  the  leg 


hill 

Ik. 

i 

n^mmjrmm-'- 

^% 

■HK.::^ 

H 

L 

HHHH 

ng 

1 

■M 

M 

Fig.  117. — Traction  b}'  Inclined  Plane. 

when  the  patient  is  turned  and  the  hip-joint  should  not  be  moved  dur- 
ing the  process.  In  cases  in  which  traction  efficiently  used  does  not 
afford  relief,  lateral  traction  may  be  added.  This  is  furnished  by 
means  of  a  cloth  band  passing  around  the  inner  side  of  the  upper  part 
of  the  thigh  which  runs  straight  out,  and  is  attached  to  a  weight  hang- 
ing over  the  edge  of  the  bed.     Resistance  to  this  pull  is  furnished  by 


TUBERCULOUS  DISEASE   OF   THE  JJI/>.  119 

another  cloth  band  running  around  the  iHum  on  the  diseased  side,  pass- 
ing around  the  patient,  and  over  the  other  side  of  the  bed  to  be  attached 
to  another  weight.  The  amount  of  these  weights  is  to  be  determined 
by  the  comfort  of  the  patient.  Traction  during  the  acute  stage  may 
also  be  furnished  during  recumbenc}-  b}-  the  application  of  a  long  trac- 
tion splint,  which  is  used  in  place  of  the  weight  and  pulley  traction. 
In  this  case  the  patient  lies  upon  the  bed-frame  wearing  the  traction 
splint.  The  use  of  the  weight  and  pulley  during  recumbency  without 
the  use  of  the  bed-frame  is  ineffectual,  as  the  patient  lies  upon  a  sag- 
ging mattress  and  fi.xation  is  not  afforded  to  the  diseased  hip. 

B.  The  Treatment  of  the  Subacute  Stage. — During   the  subacute 
stage  of  the  disease  it  is  desirable  that  the  patient  should  go  about  as 


Fig.  iiS. — Latei-al  Traction  in  Hip  Disease. 

far  as  is  compatible  with  the  welfare  of  the  diseased  hip.  The  most 
efficient  mode  of  treatment  during  this  stage  is  to  be  found  in  the  use 
of  the  traction  splint,  which  furnishes  not  only  traction,  but  also  some 
restriction  of  motion.  Unrestricted  activity  is  not  desirable  at  this 
stage.  The  patient's  day  should  be  a  short  one,  broken  by  a  period  of 
recumbenc}-.  Wliile  wearing  the  splint  the  patient  should  sleep  upon 
the  bed-frame  arranged  in  the  manner  described  in  speaking  of  the 
acute  stage  of  the  disease. 

Traction  Splixts. 

Traction  splints  exert  their  power  upon  the  joint  by  virtue  of  pull- 
ing down  the  leg  against  a  counter-point  of  pressure  furnished  by  the 
perineum.  A  number  of  appliances  have  been  devised  for  the  purpose 
of  traction,  the  principle  of  which  is  practically  the  same,  viz.,  perineal 
resistance  with  a  pulling  force  exerted  on  the  limb. 


120  ORTHOPEDIC  SURGERY. 

The  traction  splint  (^Chapter  XXL,  10)  in  common  use  is  developed 
from  the  traction  splint  originally  devised  by  Dr.  Henry  G.  Davis. 
The  modifications  by  Dr.  C.  F.  Taylor  and  Dr.  L.  A.  Sayre  were,  how- 
ever, of  great  importance  in  establishing  the  usefulness  of  the  appliance. 
A  traction  appliance  consists  of  an  outside  steel  upright  reaching  from 
the  trochanter  to  below  the  foot ;  at  the  upper  end  is  a  horizontal  rigid 
pelvic  girdle  in  which  the  patient  is  secured  by  one  or  two  perineal 
straps ;  to  the  bottom  of  the  shaft  is  attached  some  appliance  for  exer- 
cising traction  upon  the  limb,  the  latter  being  held  to  the  bottom  of  the 
splint  by  means  of  webbing  attached  to  adhesive  plaster  straps. 

The  adjustment  of  traction  is  easily  provided  for  in  se\'eral  ways. 
One  is  by  means  of  a  sliding  rod  moving  within  a  tube,  the  extension 
of  the  splint  being  controlled  by  means  of  a  key  and  ratchet,  a  catch 
securmg  the  rod  when  in  the  proper  position. 

The  lower  end  is  furnished  with  a  broadened  piece,  bent  so  as  to 
pass  under  the  foot,  and  straps  are  attached  to  it  which  can  be  buckled 
into  buckles  secured  to  the  adhesive  plaster  on  the  patient's  leg. 

A  cheaper  arrangement  for  traction  can  be  furnished  by  means  of  a 
small  windlass  on  the  footpiece  of  the  splint,  turned  by  a  key  with  a 
ratchet. 

Perineal  Bands. — These  may  be  made  of  webbing  covered  with  Can- 
ton flannel  or  chamois  skin.  Leather  sewed  smoothly  around  a  leather 
strap  is  the  cleanest  perineal  band  of  all ;  but  in  the  hands  of  careless 
persons  it  becomes  hard  with  the  constant  wetting  from  urine,  and  is 
liable  to  chafe. 

Two  perineal  bands  are  better  than  one,  as  furnishing  better  coun- 
ter-resistance to  traction  and  checks  to  adduction  of  the  limb. 

The  perineum  should  be  kept  powdered,  and  it  should  be  bathed  in 
alcohol  daily.  When  an  excoriation  appears  the  perineal  band  should 
be  covered  with  linen  which  is  well  spread  with  vaseline  or  zinc  oint- 
ment and  changed  often.  If  the  chafed  spot  becomes  worse,  the  peri- 
neal band  on  that  side  should  be  removed  and  the  other  band  entrusted 
with  the  whole  weight ;  or  the  child  should  be  put  to  bed,  the  splint 
removed,  traction  by  means  of  a  weight  and  pulle}^  in  bed  being  used 
for  a  short  time  until  the  perineum  is  healed.  Ordinarily,  with  proper 
care  and  cleanliness,  the  perineum  is  able  to  bear  after  a  short  time  all 
the  pressure  needed. 

Traction  Straps". — The  readiest  wa\"  to  obtain  the  hold  upon  the  limb 
for  an  extending  force  is  by  means  of  adhesive  plaster  applied  as  indi- 
cated in  the  diagram.  It  should  be  applied  firmly  to  the  thigh  above 
the  knee.  If  applied  to  the  leg  alone,  traction  falls  upon  the  knee  and 
may  cause  relaxation  of  the  ligaments  of  that  joint.  Efficient  plaster 
should  be  used,  of  a  kind  that  will  adhere  readily  without  being  heated. 
A  plaster  prepared  with  a  combination  of  oxide  of  zinc  will  be  found 


TUBERCULOUS  DISEASE  OF   THE  HIP. 


121 


to  irritate  the  skin  less  than  the  ordinary  surgeon's  adhesive  plaster. 
The  plasters  should  be  changed  every  three  or  four  weeks,  or  oftener 
if  they  cause  irritation.  They  can  readily  be  removed,  if  the  skin  and 
plasters  be  thoroughly  moistened  with  benzin  or  ether.  If  any  portion 
of  the  limb  is  chafed  by  the  plaster,  it  may  be  protected  by  means  of  a 


Fig.  119.— Traction  Hip  Splint  Applied, 
Front  View. 


Fig.  120.— Traction  Hip  Splint  Applied, 
Back  View. 


cloth  covered  with  ointment  placed  over  the  part,  and  the  plaster  be 
applied  over  the  cloth  and  the  whole  limb ;  or  if  the  chafing  is  exten- 
sive, the  whole  limb  can  be  covered  with  zinc  ointment  and  protected 
b\-  a  smooth  bandage,  and  the  plaster  put  on  over  the  bandaged  limb. 
This  will  require  frequent  renewal,  but  will  answer  temporaril)-.  A 
bandage  applied  over  the  plaster  impedes  the  circulation  and  increases 


122 


ORTHOPEDIC  SURGERY. 


the  danger  of  eczema  or  chafing.  If  a  bandage  is  apphed  over  the 
plaster  and  worn  for  a  few  hours  after  it  is  first  put  on,  sufficient  adhe- 
sion of  the  plaster  will  be  secured  if  proper  plaster  is  used.  In  certain 
cases  an  obstinate  eczema  is  occasioned  by  the  adhesive  plaster,  and  it 


Fig.  121.— Traction  Hip  Splint 
Applied,  Side  View. 


Fig.  122. 


-Traction  Hip  Splint,  High  Sole  and  Crutches 
Applied. 


is  necessary  to  have  recourse  to  some  other  means  of  extension.  Sub- 
stitutes for  plaster  are  to  be  found,  gaiters  applied  to  the  ankle  or 
straps  above  the  knee.  These,  however,  will  slip  if  more  than  a  slight 
traction  force  be  applied,  and  are  not  as  a  rule  satisfactory.  Another 
form  of  traction  strap  can  be  made  in  the  following  way :  Cloth  is  cut 


TUBERCULOUS  DISEASE   OE    THE  HIP. 


12 


to  fit  the  thigh  and  leg  accurately ;  webbing  straps  and  buckles  or  lac- 
ings are  attached,  which  when  tightened  give  a  hold  upon  the  thigh 
above  the  knee.  If  stra])s  are  sewed  to  this  leather  or  cloth  legging, 
they  can  be  made  to  furnish  fairly  efficient  traction ;  but  they  are  likely 
to  slip,  and  are  inferior  to  the  simple  ad- 
hesive plaster  as  a  means  of  traction. 

Application  and  Use  of  the  Traction 
Splint. — The  traction  splint  is  applied  by 
having  the  child  lie  on  the  back  while  gentle 
traction  is  made  on  the  leg  by  the  hand  to 
steady  it.  The  pelvic  band  is  passed  around 
the  child,  buckled  around  the  waist,  and  the 
perineal  bands  are  fastened.  The  traction 
straps  below   the   foot   are    then   attached 


Fig. 


-Double  Uprig-ht  Hip  Splint  Applied.    (Dane.) 


Fig.    124. — Leather    Spica   Trac- 
tion Splint. 


to  the  windlass  or  whatever  extending  apparatus  is  used,  and  as  much 
traction  applied  as  the  child  can  comfortably  stand.  The  straps  around 
the  leg  are  then  fastened.  When  it  is  necessary  to  remove  the  splint 
or  loosen  the  traction  to  care  for  the  perineum,  traction  should  be  made 
upon  the  leg  by  the  hand. 

Crutches. — With  an  efficient  traction  splint  thoroughly  applied,  a 
sufficient  amount  of  restraint  of  motion  at  the  hip-joint  can  be  furnished 


124  ORTHOPEDIC  SURGERY. 

to  enable  a  patient  not  in  the  acute  stage  of  the  disease  to  move  about 
with  tlie  aid  of  crutches,  the  well  limb  being  elevated  by  a  raised  shoe. 
In  cases  with  any  tendency  to  acuteness,  however,  thorough  traction 
is  essential,  and  walking  on  a  traction  splint  without  crutches  is  liable 
to  cause  perineal  chafing  and  less  efficient  traction,  as  at  each  step  on 
the  splint  the  traction  force  is  somewhat  diminished,  on  account  of  the 
yielding  of  the  perineal  straps.  In  cases  in  which  convalescence  has 
been  established,  crutches  may  be  dispensed  with  and  less  traction 
exerted. 

Modified  Traction  Splints. — Various  modifications  of  the  traction 
splint  have  been  made,  in  the  hope  of  securing  greater  fixation  in  con- 
nection with  the  traction  and  in  this  way  to  enable  free  locomotion 
without  endangering  the  joint.  The  splint  devised  by  Dane  (Chapter 
XXI.,  13)  and  the  combination  of  the  traction  splint  with  a  plaster  or 
leather  spica  represent  the  most  efficient  forms  of  this  apparatus.  The 
objection  to  such  appliances  is  that  they  neither  fix  the  joint  nor  do 
they  permit  as  efficient  traction  as  that  furnished  by  the  traction  splint 
without  a  modification.  The  arm  extending  up  to  grasp  the  pelvis  or 
thorax  acts  as  a  lever  which  jars  the  hip  as  the  trunk  moves,  and  the 
greater  the  traction  used  the  more  injurious  is  the  lever  action. 

A  plaster-of-Paris  bandage  over  the  trunk  and  affected  limb  (as  far 
as  the  knee),  over  which  a  traction  apparatus  is  applied,  the  traction 
straps  being  placed  on  the  limb  before  the  plaster  bandage  is  put  on, 
furnishes  probably  the  most  effective  combination  of  traction  and  par- 
tial fixation.  Less  cumbersome  than  the  plaster,  but  not  as  easily  fur- 
nished, is  a  moulded  leather  spica  splint  made  over  a  cast  by  a  similar 
process  of  manufacture  to  that  described  in  speaking  of  leather  jackets 
(Chapter  XXI.,  3).  Still  another  arrangement  can  be  furnished  if  a 
cloth  corset  with  lacing  be  made,  enclosing  the  trunk  and  limb  and 
attached  to  a  Thomas  hip  splint  (Chapter  XXI.,  13).  If  this  is  laced 
snugly  to  the  patient  the  child  can  be  lifted  with  but  little  jar  to  the 
hip,  and  a  traction  splint  can  be  applied  wdth  but  little  additional  diffi- 
culty. This  combination  is  of  service  in  exceptional  cases  in  which  the 
acute  stage  is  longer  than  usual,  but  it  is  not  necessary  in  ordinary 
cases  in  which  a  comparatively  short  thorough  treatment  by  recumbency 
is  followed  by  a  subacute  stage  where  the  limitation  to  the  hip  motion 
is  furnished  by  a  well-applied  traction  splint. 

Fixation  Splints. 

Ambulatory  treatment  by  means  of  so-called  fixation  appliances 
without  traction  has  been  tried  in  many  cases  for  many  years  at  the 
Boston  Children's  Hospital.  The  results  in  comparison  with  those 
obtained  where  traction  was  efficiently  and  carefully  applied  to  sim- 
ilar cases  justify  a  strong  statement  as  to  the  superiority  of  the  em- 


TUBERCULOUS  DISEASE   OF    TIJE  HIP. 


125 


ployment  of  traction  in  the  subacute  stages  of  hip  disease,  not  only 
on  theoretical  grounds,  but  because  of  the  superiority  of  the  results 
obtained  as  observed  in  a  large  number  of  cases  carefully  treated  and 
carefully  recorded. 

Ambulatory  treatment  by  partial  fixation  without  traction  may  be 
needed  when  but  little  nursing  care  can  be  furnished,  and  the  surgeon 
should  be  familiar  with  the  best  methods  of  its  employment.  It  is 
manifest  that  thorough  hip  fixation  cannot  be  given  if  the  patient  is 
allowed  to  move  about,  as  the  pelvis  cannot  be  thoroughly  secured  by 
any  bandage  or  appliance.  It  is  also  true  that  the  method,  although 
imperfect,  is  better  than  no  treatment.  Through  its  use  patients  may 
be  relieved  of  the  acute  symptoms. 

Plaster-of-Paris  Splint. — The  hip-joint  may  be  fairly  well  immobil- 
ized by  a  plaster-of-Paris  spica  reaching  from  the  axillae  to  the  heel. 


Fig.  125. — Application  of  Plaster  Spica  Hip  Bandage. 

It  is  made  more  efficient  if  the  other  limb  is  included  by  a  double  spica, 
which,  however,  prevents  locomotion.  With  a  bandage  applied  to  one 
leg  alone  the  patient  can  go  about  on  crutches  wearing  a  high  shoe  on 
the  other  foot.  This  forms  the  routine  of  treatment  in  many  Euro- 
pean clinics,  but  the  amount  of  effective  fixation  furnished  is  limited. 
The  aim  of  this  treatment  is  well  expressed  by  a  representative  French 
surgeon  writing  as  follows :  "  It  is  ankylosis  in  good  position  that  we 
pursue  as  the  ideal  of  a  cure  in  coxalgia."  ' 

What  has  been  said  of  the  plaster-of-Paris  spica,  even  when  so 
applied  as  to  hold  the  thorax  and  the  other  leg,  is  true  of  metal  and 
leather  splints,  which  do  not  so  completely  hold  the  joint  as  that  does. 
These  lack  fixative  power  by  virtue  of  the  little  hold  which  they  have 
upon  the  pelvis,  and  although  in  many  cases  of  hip  disease  they  serve  a 

'  "  Late  Excision  of  the  Hip."     Boston  Med.  and  Surg.  Journ.,  July  ist,  1897. 


126 


ORTHOPEDIC  SURGERY. 


therapeutic  purpose  in  acting  as  an  incomplete  means  of  fixation,  they 
cannot  be  advocated  for  general  use. 

The  Thomas  Splint. — The  Thomas  hip  splint  (Chapter  XXI.,  13), 
invented  by  H.  O.  Thomas,  of  Liverpool,  is  an  appliance  much  in  use 
in  England.  It  is  a  very  simple  apparatus,  easily  made,  and  having 
many  points  of  usefulness.  It  consists  of  an  iron  bar  extending  down 
the  back  of  the  body  and  the  diseased  leg  to  a  little  above  the  ankle ; 
the  upper  end  of  this  is  attached  to  a  chestpiece  which  is  at  right  angles 

to  the  upright  and  en- 
circles the  chest,  fasten- 
ing in  front.  There  are 
two  circlets  of  iron 
which  grasp  the  thigh 
and  calf.  The  appli- 
ance  is    kept   in  place 


Fig.  126.— Plaster  SpicaHip  Bandage. 


Fig.  127.  —  Thomas'  Splint 
Applied,  Posterior  View. 
(Ridlon.) 


by  a  wide  chest  band  and  a  bandage  around  the  limb,  and  can  be 
bent  to  fit  any  degree  of  flexion  existing  in  the  diseased  leg  and 
applied  to  it  in  that  position.  The  apparatus  requires  much  skill  in 
adjustment,  as  it  is  hard  to  fit  and  keep  in  place.  There  are  two  points 
in  the  use  of  the  splint  upon  which  Thomas  laid  much  stress.  The 
patient  must  not  go  about  while  muscular  spasm  and  joint  irritability 
are  present,  and  the  limb  must  not  be  disturbed  even  for  purposes  of 
examination  unless  absolutely  necessary,  and  then  only  at  intervals  of 


TUBERCULOUS  DISEASE   OE   THE  HIP.  127 

months.  The  appHance  prevents  motion  of  any  great  amount,  enables 
the  patient  to  be  Hfted  without  jarring  the  hip,  and  prevents  and  cor- 
rects flexion  of  the  thigh.  In  certain  acute  cases  the  pain  ma)'  be  in- 
creased by  the  Thomas  sphnt,  from  the  fact  of  the  imperfect  fixation 
furnished.  For  motion  at  the  hip  cannot  be  prevented  as  the  leg  and 
thigh  are  firmly  held  by  the  fiat  rod  to  which  they  ai^e  bandaged,  and, 
as  this  rod  extends  up  the  trunk,  to  which  it  cannot  be  so  firmly  fixed 
as  to  prevent  all  motion  when  the  patient  turns  in  bed  or  moves.  The 
upper  end  of  the  rod  acts  as  the  long  arm  of  a  lever,  moving  with 
every  respiration  if  tightly  applied,  and  on  moving  jarring  the  hip. 

A  double  Thomas  splint  is  more  efficient  as  a  means  of  fixation,  but 
it  does  not  permit  locomotion.  In  a  single  Thomas  splint  a  raised  pat- 
ten is  put  under  the  shoe  of  the  well  foot  and  crutches  are  used. 

Immobilization  and  Ankylosis.  — Much  has  been  written  in  reference 
to  the  danger  of  ankylosis  incurred  by  the  immobilization  of  diseased 
joints. 

That  fixation  of  a  healthy  joint  even  for  prolonged  periods  does  not 
cause  ankylosis  has  been  demonstrated.'  The  most  common  cause  of 
ankylosis  in  diseased  joints  is,  of  course,  in  the  cicatrization  of  the 
inflamed  tissues.  Any  measure  which  tends  to  limit  inflammation 
tends  materially  to  limit  rather  than  increase  the  ultimate  impairment 
of  motion. 

Treatment  of  the  Stage  of  Convalescence. — Protection  of  the  joint 
from  the  whole  or  part  of  the  jar  in  walking  is  useful  in  the  convales- 
cent stage  of  hip  disease.  The  need  of  this  will  be  readily  understood 
if  it  is  remembered  that  in  ordinary  walking  the  whole  weight  of  the 
body  falls  upon  the  hip  when  the  limb  is  straightened  and  the  heel 
strikes  the  ground.  A  tuberculous  hip  may  be  sufficiently  cicatrized  to 
resist  slight  injury,  while  the  frequent  impact  of  a  weight  of  upward  of 
forty  pounds  may  in  time  produce  a  condition  of  congestion  which  will 
furnish  a  cause  for  lighting  up  a  quiescent  focus  of  tuberculosis. 

The  simplest  way  to  protect  a  joint  is  with  the  use  of  crutches,  the 
sound  limb  being  raised  by  means  of  a  patten  on  the  shoe  of  the  sound 
limb,  enabling  the  affected  limb  to  swing  free  of  the  floor. 

Protection  Splints. 

The  ordinary  "traction  "  splint,  as  described,  can  be  used  as  a  pro- 
tecting splint,  as  it  is  longer  than  the  limb  and  passes  under  the  foot, 
enabling  the  weight  to  be  borne  upon  the  splint  instead  of  on  the  pa- 
tient's foot.  Protection  without  traction  (Chapter  XXI.,  11)  can  be 
furnished  by  omitting  the  sliding  rod,  and  continuing  the  upright  rod 
below  the  foot,  and  expanding  it  at  the  bottom  into  a  crutch  bottom  to 
be  shod  with  a  rubber  tip  running  down  at  the  outside  of  the  foot,  or 
'N.  Y.  Med.  Jour.,  May  17th,  1S90. 


12! 


ORTHOPEDIC  SURGERY. 


by  inserting'  it  into  a  socket  in  the  boot.  Tlie  upright  of  the  splint 
should  be  long  enough  that  the  patient's  heel  should  not  touch  the 
sole  of  the  boot,  though  the  ball  of  the  foot  may  do  so.  The  greatest 
jar  in  locomotion  comes  as  the  heel  strikes  the  ground  at  the  com- 
mencement of  the  step.  If  this  jar  is  broken  by  the  splint,  the  remain- 
ing jar  to  the  hip  in  the  step  will 
be  diminished  at  the  ankle  and 
knee,  and  the  hip  sufficiently  pro- 
tected, except  during  the  acute 
stasres  of  the  disease. 


Fig.  128.— Crutch  Tip   Convalescent    Hip 
Splint,  Applied. 


Fig. 


Jointed     Convalescent     Hip 
Splint,  Applied. 


The  ordinary  protection  splint  should  be,  like  the  long  traction  splint, 
an  outside  steel  upright  with  a  horizontal  pelvic  band  at  a  level  with 
the  trochanter  carrying  perineal  straps.  It  should  be  slotted  below 
into  a  steel  sole  plate  screwed  to  the  bottom  of  the  sole,  and  when  the 
splint  is  in  place  and  the  perineal  band  buckled,  the  patient's  heel 
should  not  touch  the  heel  of  the  shoe,  but  hang  an  inch  or  less  above 
it.  A  protection  splint  can  be  made  hinged  at  the  knee,  and,  if  prop- 
erly adjusted,  patients  can  walk  about  readily  with  but  slight  discom- 


TUBERCULOUS  DISEASE   OE   THE  HIP.  129 

fort.  In  this  way  reliable  protection  is  secured  during  the  long  period 
of  convalescence  necessary  for  the  thorough  recovery  of  the  affected 
epiphysis.' 

If  proper  protection  is  neglected  and  not  continued  long  enough,  the 
jar  of  locomotion — the  whole  weight  being  thrown  upon  the  epiphysis 
previously  diseased — is  sufficient  to  prolong  the  stage  of  irritability,  to 
prevent  complete  cicatrization  and  ossification  of  the  inflamed  bone 
tissue,  to  promote  contraction  of  the  limb  and  distortion,  and  in  many 
instances  to  give  rise  to  relapses. 

It  is  not  necessary  in  young  children  that  the  splint  be  jointed  at  the 
knee  in  a  protection  splint ;  this  is,  however,  of  advantage  in  adults. 
As  the  patient's  condition  improves,  the  splint  can  be  shortened  and  jar 
gradually  be  allowed  to  come  upon  the  limb.  Protection  is  needed  for 
some  years  after  the  subsidence  of  active  symptoms.  The  need  for  the 
reapplication  of  protection  is  indicated  by  a  reappearance  of  stiffness  or 
increased  limping  on  removal  of  the  splint.  The  older  the  patient  and 
the  more  active  the  process  the  longer  protection  will  be  needed. 

Relapses. — Hip  disease  is  not  ended  when  the  acute  symptoms  have 
subsided ;  a  process  which  requires  so  long  a  time  for  its  development 
requires  also  much  time  for  its  disappearance.  It  is  safer  not  to  dis- 
continue traction  and  begin  simply  protective  treatment  as  soon  as  the 
pain  and  acute  symptoms  are  gone,  and  it  is  safer  not  to  discontinue 
protective  treatment  until  a  long  time  has  been  given  to  the  joint  in 
which  to  recover  itself. 

Termination  of  Treatment. — Patients  apparently  cured  in  childhood 
of  hip  disease,  but  with  fixed  or  partially  fixed  joints,  may  suffer  in  later 
life  from  painful  attacks  from  overstrain  of  the  ligamentous  attach- 
ments of  the  joints;  this  is  especially  true  if  any  distortion  remains  un- 
corrected and  the  patient  becomes  heavy.  This  painful  stage  yields  to 
the  treatment  by  protection  for  a  short  time.  If,  however,  much  deform- 
ity persists,  correction  of  the  deformity  is  often  necessary.  Recur- 
rence of  the  tuberculous  process  in  adult  life  in  a  hip  which  has  been 
thoroughly  cicatrized  since  childhood  is  rare. 

When  ambulatory  treatment  is  attempted  it  is  desirable  that  every 
precaution  against  jar  to  the  hip  be  taken.  As  it  becomes  clear  that 
the  danger  of  motion  or  jar  at  the  hip  has  diminished,  crutches  can  be 
laid  aside  for  part  of  the  time,  with  the  continuance  of  traction  as  long 
as  there  is  a  tendency  to  contraction  of  the  limb  or  muscular  spasm. 
Later  traction  may  be  discontinued,  but  protection  still  maintained. 

Traction  should  be  given  up  only  after  the  muscular  irritability 
elicited  by  gentle  manipulation  has  been  absent  for  some  weeks,  until 
pain  and  night  cries  have  been  absent  for  months,  and  until  there  is 

'  "  Mechanical  Treatment  of  Hip-joint  Disease,"  C.  F.  Taylor,  New  York  ;  and 
E.  G.  Brackett :  Boston  Medical  and  Surgical  Journal,  October  6th,  1887. 
Q 


130  ORTHOPEDIC  SURGERY. 

every  reason  to  believe  that  the  process  is  quiescent  and  only  partial 
stiffness  of  the  joint  remains,  due  to  inflammatory  adhesions  and  not  to 
muscular  spasm,  and  that  protective  treatment  should  then  be  pursued 
for  two  or  three  years  at  least  and  discontinued  gradually. 

Summary  of  Mechanical  Treatment. — A  systematic  and  graded 
treatment  of  hip  disease  is  in  this  way  provided,  capable  of  meeting  the 
successive  indications  in  the  usual  course  of  a  typical  acute  hip  disease 
in  its  progress  from  an  early  destructive  stage  to  recovery,  first,  by 
thorough  fixation  with  protection  of  the  joint  from  muscular  spasm 
and  traumatism;  second,  by  locomotion  with  a  minimum  of  motion  at 
the  hip  and  protection  of  the  joint  from  jar,  with  a  check  to  exaggerated 
intraarticular  pressure  from  muscular  spasm ;  and  third,  by  freer  motion 
at  the  hip,  but  with  protection  of  the  hip  from  the  jar  incidental  to 
walking  and  a  check  to  the  development  of  deformity. 

As  cases  vary,  the  treatment  will  be  changed  to  meet  the  variations 
according  to  the  judgment  of  the  surgeon.  The  period  of  fixative 
recumbency,  which  should  be  as  short  as  possible,  will  in  some  cases  be 
longer  than  others,  owing  to  the  activity  of  the  inflammatory  process. 
In  some  cases  ambulatory  treatment  can  be  begun  at  once  without  the 
stage  of  thorough  fixation  with  recumbency.  This  course  of  treatment 
is  inadvisable  while  deformity  or  acute  spasm  is  present,  but  may  be 
demanded  by  the  necessity  of  the  case.  In  some  instances  an  increased 
risk  to  the  local  lesion  may  be  justified  to  improve  through  greater 
activity  the  general  condition. 

The  application  of  traction  in  hip  disease  to  be  of  benefit  needs  to 
be  carefully  directed.  As  in  aseptic  surgery  vigilance  and  efficiency  on 
the  part  of  attendants  are  necessary,  while  as  in  aseptic  surgery  a  par- 
tial adoption  of  the  method  is  better  than  its  total  rejection,  yet  the 
method  is  injurious  if  its  imperfect  use  blinds  the  surgeon  to  the  neglect 
of  other  essentials.  A  surgeon  is  not  employing  the  aseptic  method  of 
treatment  if  he  washes  his  hands  in  sterile  solutions  and  poisons  the 
wound  with  septic  dressings.  In  a  similar  way  the  use  of  a  traction 
splint  in  the  case  of  a  child  with  hip  disease  is  not  only  not  beneficial, 
but  becomes  injurious  if  it  leads  the  surgeon  to  neglect  the  necessity  of 
protecting  an  inflamed  joint  from  undue  motion. 

The  care  required  in  the  application  of  traction  splints  and  the  un- 
satisfactory results  following  apparent  treatment  by  traction  splints  in 
out-patient  clinics  have  led  many  surgeons  to  abandon  the  use  of  the 
so-called  traction  splints,  allowing  the  patient  to  walk  about  with 
crutches,  with  the  thigh,  leg,  and  trunk  supported  by  fixation  appliances. 

The  Treatment  of  Complications. 

Abscess. — Abscesses  due  to  hip  disease  may  in  the  early  stages  be 
absorbed  in  some  cases  under  prolonged  treatment  by  recumbency. 


TUBERCULOUS  DISEASE   OF   THE  HIP.  131 

Abscesses  may  also  be  left  to  enlarge  and  break  if  for  any  reason 
this  seems  desirable  in  any  individual  case.  If  abscesses  are  well  local- 
ized and  increasing  in  size,  and  burst  spontaneously,  they  often  are  thor- 
oughly evacuated,  leaving  a  sinus  which,  after  discharging  for  some 
time,  finally  heals.  Often,  however,  the  abscess  is  not  completely 
evacuated.  Some  residue  remains,  and,  gravitating  along  the  lines  of 
fasciae,  it  gives  rise  to  the  development  of  another  abscess,  until  several 
collections  of  pus  may  be  developed  about  the  joint. 

The  experience  of  the  writers  in  treatment  by  aspiration  and  the 
injection  of  germicidal  solutions  has  not  been  favorable  for  the  same 
reasons  as  those  mentioned  in  speaking  of  Pott's  disease.' 

Incision  under  strict  antiseptic  precautions  is  to  be  advised  in  all 
cases  in  which  absorption  seems  unlikely;  exploration  of  the  joint  cav- 
ity should  be  made  if  the  abscess  communicates  freely  with  it,  and  pos- 
sibly softened  bone  may  be  scraped  out.  The  abscess  cavity  should  be 
examined  for  pockets,  wiped  out  with  dry  gauze,  and  drained.  Sinuses,, 
as  a  rule,  persist  for  months  or  years  after  operation." 

When  efficient  treatment  is  carried  out,  abscesses  as  a  rule  appear 
only  in  the  severer  cases,  in  which  drainage  is  likely  to  be  of  benefit  to 
the  disease.  The  closure  of  abscess  cavities  by  suture  after  the  evacua- 
tion of  their  contents,  while  in  rare  instances  it  leads  to  permanent 
union  by  first  intention,  is  not  to  be  advised,  as  breaking  down  gen- 
erally occurs  subsequently.  It  must  be  remembered  that  the  tubercu- 
lous infection  is  not  confined  to  the  wall  of  the  abscess,  but  extends 
into  the  surrounding  tissues. 

Night  Cries. — This  troublesome  complication  usually  disappears 
quickly  after  the  establishment  of  thorough  treatment  by  recumbency 
and  strong  efficient  traction.  It  is  indicative  of  an  active  condition  of 
the  process  of  epiphyseal  ostitis.  In  some  instances  it  persists  for  sev- 
eral weeks  even  under  treatment.  In  such  cases  an  abscess  is  usually 
developed.  The  employment  of  phenacetin  and  salicylate  of  soda ''  has 
appeared  to  be  of  some  efficiency  in  diminishing  night  cries.  Although 
opiates,  chloral,  and  bromide  of  potassium  in  large  doses  will  often  give 
relief,  the  use  of  them  is  to  be  avoided  if  possible. 

Deformity. — The  deformities  occurring  are  flexion,  abduction,  and 
adduction,  or  any  combination  of  these.  In  the  early  stages  of  the  dis- 
ease when  malposition  occurs  it  is  best  corrected  by  putting  the  patient 
to  bed  and  making  traction  in  the  line  of  the  deformity. 

Correction  by  the  Traction  Splint. — Slight  cases  of  deformity 
can  be  corrected  by  the  use  of  traction  splints,  which  allow  the  patient 

'  N.  Y.  Med.  Jour.,  March  2d,  1889. 

■Boston  Med.  and  Surg.  Jour.,  September  iSth,  1S90.  — Orth.  Trans.,  vol.  ii., 
p.  87. 

■R.  \V.  Lovett:  Boston  Medical  and  Surgical  Journal.  April.  1S89. 


132 


ORTHOPEDIC  SURGERY. 


to  go  about  with  the  aid  of  crutches.  The  traction  splint  naturally 
antagonizes  adduction  of  the  limb  by  virtue  of  its  pulling  the  leg  against 
a  counter-point  in  the  perineum  which  tends  to  abduct  the  leg  to 
which  the  splint  is  applied. 

Correction  by  Recumben'CY. — In  the  severer  cases  rest  in  bed 
hastens  correction.  If  the  patient  is  allowed  to  roll  about  in  bed,  or 
sit  up,  or  hold  the  limb  flexed  at  the  knee,  it  is  manifest  that  no  proper 
traction  force  is  being  used. 
It  is  obvious,  therefore, 
that  the  patient  should  be 
fastened  to  a  bed  frame 
and  traction  made  in  the 
line  of  deformity.     As  the 


Fig.  130.— Diagram  to  illus- 
trate the  performance  of 
sub-trochanteric  osteoto- 
my for  the  correction  of 
ankylosis  of  the  hip  in  a 
deformed  position.  The 
solid  line  indicates  a  linear 
osteotomy  ;  the  dotted  and 
solid  lines  tog'ether,  a 
wedge-shaped  osteotomy. 


Fig.  131. — Adduction  Deformity  Resulting  from 
Hip  Disease  before  Correction.    (C.  F.  Painter.) 


malposition  of  the  leg  diminishes  under  treatment,  the  line  of  the 
pull  is  made  gradually  more  in  the  long  axis  of  the  body.  The 
ill  effect  of  a  pulling  force  not  in  the  line  of  the  deformity  in  the 
acute  stages  of  hip  disease  is  evident.  If  an  attempt  is  made  to  force 
the  limb  down  in  a  case  of  flexion,  and  a  pull  be  made  in  the  line  of  the 
axis  of  the  body,  the  head  of  the  femur  is  crowded  upward  to  the  ante- 
rior edge  of  the  acetabulum  by  the  force  applied  at  the  end  of  the  lever, 
viz.,  the  femur,  the  contraction  of  the  flexor  muscles  (holding  the  limb 
flexed)  furnishing  the  fulcrum.  In  milder  stages  of  the  disease  this  is 
not  so  important  as  in  the  acuter  stages,  but  it  is  a  mechanical  error  in 


TUBERCULOUS  DISEASE   OE    THE  HIT. 


133 


any  stage  to  attempt  traction  except  in  the  line  of  the  deformity.  This 
error  is  often  the  occasion  of  increasing  the  pain  and  sensitiveness  in 
cases  of  hip  disease. 

Correction  Under  an  An/ESthetic. — In  cases  of  resistant  defor- 
mity treatment  by  traction  is  tedious  and  in  the  more  obstinate  cases  in- 
effectual. In  cases  of  this  character  the  use  of  judicious  force  under  an 
anaesthetic  is  advisable.  Care  must  be  exercised  not  toinfiict  a  trauma 
upon  tuberculous  bone,  but  where 
resistance  is  firm,  cicatrization  of 
the  diseased  area  can  be  supposed 
to  have  taken  place,  and  often  but 
little  force  is  necessary  to  secure 
correction.  Division  of  the  con- 
tracted fascia  lata  and  adductor 
muscles  will  be  of  assistance  in 
some  instances.  After  correction 
the  limb  should  be  fixed  in  a 
plaster-of-Paris  spica  bandage,  a 
corrected  position  with  slight  ab- 
duction. When  firm  ankylosis  is 
present  manual  correction  will  not 
be  sufficient  and  recourse  to  oste- 
otomy will  be  needed. 

Correction  by  Osteotomy. — 
The  operation  in  common  use  was 
devised  by  Gant ; '  in  this  the  femur 
is  divided  below  the  trochanter 
minor.  The  anatomical  reasons 
which  he  gave  for  this  step  were 
that  the  resistance  of  the  psoas 
and  iliacus  muscles  was  set  free 
and  that  a  return  of  the  flexion 
was  not  therefore  to  be  expected, 
as  when  the  bone  was  divided 
above  the  attachment  of  these  muscles.  He  also  called  attention  to 
the  fact  that  in  operating  for  ankylosis,  after  hip  disease,  it  was 
desirable,  if  possible,  to  make  the  section  through  healthy  bone  and  as 
far  as  possible  from  the  original  seat  of  the  disease ;  in  this  way  dimin- 
ishing the  liability  of  rekindling  the  old  joint  inflammation. 

Tcchniqjie  of  Operation. — The  osteotome  is  a  chisel,  which  should 
possess  a  temper  about  halfway  between  that  of  a  cold  chisel  and  a  car- 
penter's cutting  tool,  so  that  the  QdgQ  of  it  will  not  be  turned  by  the 
hardness  of  the  bone.     The  cutting  edge  should  be  sharp  and  the  width 
'  Lancet,  December,  1872,  p.  881. 


Fig.  132.— Adduction  Deformity  Resulting 
from  Hip  Disease  after  Correction.  (C.  F. 
Painter.)     Same  patient  as  Fig.  131. 


134 


ORTHOPEDIC  SURGERY. 


of  the  blade  about  half  an  inch.  The  blade  should  be  marked  with  a 
line  every  half  or  quarter  of  an  inch  from  the  cutting  edges,  so  that  one 
can  tell  how  deeply  the  osteotome  has  penetrated.  A  fair-sized  wooden 
carpenter's  mallet  answers  better  than  any  of  the  lead  or  steel  ones 
found  in  the  instrument-shops. 

In  the  performance  of  the  operation  the  patient  lies  on  the  side  with 
a  sand  pillow  between  the  legs,  and  the  skin  is  sterilized  carefully.  The 
chisel  may  be  driven  in  through  the  sound  skin  about  an  inch  or  an 

inch  and  a  half  below  the  great 
trochanter,  according  to  whether 
one  is  operating  upon  an  ado- 
lescent or  an  adult.  The  chisel 
should  at  first  be  held  with  the 
blade  in  the  long  axis  of  the 
limb  and  turned  when  it  reaches 
the  bone  until  its  edge  is  at  right 
angles  to  the  axis  of  the  limb. 
The  osteotome  should  then  be 
driven  into  the  bone  by  sharp 
blows  with  the  mallet,  turning 
the  cutting  edge  first  forward 
and  then  backward,  so  as  to  cut 
obliquely  through  the  whole 
shaft.  If  the  osteotome  be- 
comes wedged  it  should  be 
loosened  by  lateral  motions  and 
a  thinner  one  substituted  if 
possible.  Any  attempt  at  pry- 
ing with  the  osteotome  may  re- 
sult in  breaking  the  blade  and 
should  be  avoided.  When  the 
spongy  tissue  has  been  traversed 
by  the  blade  of  the  chisel,  it  will 
come  in  contact  with  the  opposite 
wall  of  solid  outside  bone  and 
will  at  once  be  felt  to  be  driven  with  greater  resistance.  Then  the  osteo- 
tome acts  as  a  probe  as  well  as  a  cutting  instrument.  The  bone  should 
not  be  entirely  divided,  but  when  it  seems  evident  that  only  a  shell  is 
left,  attempt  should  be  made  to  fracture  the  femur — very  little  force  is 
needed,  and  if  the  bone  does  not  yield  easily  the  chisel  should  be  again 
driven  in  still  farther — always  loosening  it  after  each  blow  of  the  mallet 
and  directing  the  blade  in  a  new  direction. 

After  the  bone  is  broken,  in  most  cases  the  flexed  leg  can  be  ex- 
tended and  the  adducted  one  brought  straight,  and  no  unnecessary 


Fig.  133.  — Ankylosis  at  a  Right  Angle  following 
Hip  Disease,  before  Gant's  Osteotomy.  (C.  F. 
Painter.) 


TUBERCULOUS  DISEASE   OF    THE  HIP. 


135 


manipulation  of  the  bone  should  be  made.  If  the  osteotomy  has  been 
efficiently  performed  little  force  is  needed  to  correct  the  deformity. 
There  is  little  bleeding  and  a  small  skin  wound,  unless  it  is  necessary, 
as  sometimes  happens,  to  make  a  cut  in  the  anterior  surface  of  the 
upper  thigh,  to  divide  bands  of  contracted  fascia  which  prevent  full 
extension  of  the  thigh.  The  patient  should  then  be  fixed  in  a  carefully 
applied  plaster  spica  bandage,  which  should  secure  the  hip  firmly  in  the 
corrected  position.     The  anterior  spines,  the  patella,  and  the  vertebral 


Fig.  134. — Same  Patient  as  Shown  in  Fig.  133, 
after  Osteotomy.     (C.  F.  Painter.) 


Fig.     135.— Double      Thomas 
Splint  Applied. 


Hip 


spines  should  be  well  protected  by  padding  to  prevent  sloughs.  When 
plaster-bandage  fixation  is  undesirable,  on  account  of  the  condition  of 
the  skin,  the  patient  should  be  placed  on  a  bed-frame  and  a  traction 
weight  applied,  pulling  in  the  desired  direction. 

Confinement  to  bed  should  last  between  five  and  six  weeks.  If 
it  is  desired  to  compensate  for  bone  shortening  it  can  be  done  by  put- 
ting up  the  shortened  leg  in  an  abducted  position.  The  latter  will  be 
found  of  assistance  where  the  shortening  is  great,  as  the  resulting  tilt- 
ing of  the  pelvis  adds  to  the  practical  length  of  the  limb.     The  risks 


136  ORTHOPEDIC  SURGERY. 

attending  the  operation  are  slight.  Hemorrhage  is  very  rare — although 
accidents  have  been  reported  from  pressure  on  the  femoral  vessels  by- 
sharp  edges  of  bone.^  Marked  improvement  in  the  general  condition 
of  the  patient  often  follows  the  operation.^ 

After-Treatment. — After  the  cessation  of  bed-treatment,  fixation  in 
a  plaster-of-Paris  spica  should  be  continued  for  at  least  six  weeks  more. 
If  fixation  in  the  improved  position  is  abandoned  too  early  the  deformity 
may  recur.  Deformity  occurring  during  the  acute  stage  of  the  disease 
should  be  rectified  as  it  occurs  and  prevented  from  recurring. 

The  ultimate  functional  results  following  the  operation  are  excellent. 
Although  there  may  be  no  motion  at  the  hip-joint,  the  lumbar  vertebrae 
are  usually  more  movable  than  normal.  The  operation  is  indicated  in 
all  cases  of  severe  deformity  in  which  the  distortion  interferes  seriously 
with  locomotion. 

Shortening  of  the  Limb. — Shortening  of  the  limb  after  hip-joint  dis- 
ease and  after  excision  occurs  in  a  certain  number  of  cases ;  nothing 
can  be  done  to  prevent  it  when  it  is  due  to  arrest  of  growth.  Preven- 
tion of  the  development  of  the  disease  and  such  use  of  the  limb  as  is 
compatible  with  the  safety  of  the  joint,  inducing  proper  circulation  in 
the  limb,  may  be  regarded  as  the  only  means  at  our  command.  The 
shortening  due  to  subluxation  is  in  a  large  measure  prevented  by  efficient 
treatment. 

Patients  with  much  shortening  of  the  diseased  leg  vary  a  great  deal 
in  the  relief  afforded  b}-  a  high  shoe;  sometimes  they  find  it  of  the 
greatest  possible  benefit,  while  at  other  times  it  is  a  constant  annoy- 
ance. The  shoe  can  be  raised  by  a  cork  sole,  or  more  cheaply  by  an 
iron  or  wooden  patten,  or  by  an  arrangement  in  which  the  foot,  like  the 
stump  of  an  amputated  limb,  fits  into  the  socket  of  a  specially  con- 
structed elongated  boot,  which  conceals  the  shortening. 

Double  Hip  Disease. — During  the  acute  stage  of  the  disease  recum- 
bency on  a  bed-frame  and  efficient  traction  by  weight  and  pulley  or  by 
two  traction  splints  is  the  best  treatment.  After  the  stage  of  spasm 
has  passed,  the  patient  can  be  carried  about  in  a  double  Thomas  splint 
and  when  convalescence  is  established,  locomotion  with  traction  or  pro- 
tection splints  and  crutches  is  possible.  The  chief  difficulty  in  treating 
double  hip  disease  is  in  the  prevention  of  deformity,  not  so  much  dur- 
ing the  active  stage  of  the  disease,  but  after  convalescence  has  been 
established. 

Deformity  will  probably  not  occur  if  patients  are  kept  recumbent 
for  a  sufficiently  long  time  to  establish  a  perfect  cure.  If,  however, 
they  are  allowed  to  walk  or  move  too  soon,  before  the  joints  are  thor- 

'Post:  Ann.  Anat.  and  Surg. ,  January,  1SS3.  and  Rev.  de  Chir.,  December, 
1S81. — C.  T.  Poore  :  "  Osteotomy  and  Osteoclasis,"  New  York,  18S4. 
•  Goldthwait :  Orth.  Trans.,  vol.  xi.,  p.  2S0. 


TUBERCULOUS  DISEASE   OF   THE  HIP.  137 

oughly  strong,  weight  must  necessarily  fall  upon  the  affected  limbs  in 
walking.  If  these  are  not  sufficiently  recovered  to  sustain  the  weight, 
deformity  may  ensue.  Even  with  very  little  motion  in  either  hip-joint 
locomotion  is  often  possible,  although  the  gait  is  necessarily  restricted. 

OPERATIVE   TREATMENT. 

Curetting  and  Drainage  of  Tuberculous  Areas  in  Hip  Disease. — In 
cases  of  tuberculous  ostitis  of  the  hip,  when  the  process  is  limited  to 
sharply  defined  foci  surrounded  by  firm  bone,  the  condition  may  be  said 
to  resemble  that  presented  by  an  abscess,  and  drainage  of  such  a  focus 
is  desirable  when  the  part  affected  is  easily  accessible,  as  in  the  knee  or 
OS  calcis.  But  when  the  acetabulum  or  the  epiphysis  of  the  femoral 
head  are  attacked,  it  is  difficult  to  secure  satisfactory  drainage  and  the 
removal  of  all  diseased  tissue ;  nor  is  it,  as  a  rule,  easy  in  this  region  to 
determine,  by  means  of  a  skiagram,  the  existence  of  a  sharply  defined 
focus.  It  has  been  shown  '  that  tuberculous  changes  may  exist  in  bone 
in  an  early  stage  of  development  and  on  the  borders  of  apparent  tuber- 
culous cavities,  and  yet  not  be  demonstrable  in  ,t'-ray  pictures  taken  of 
living  subjects,  especially  when  taken  in  the  deeper  structures.  This 
procedure  is  most  satisfactory  when  the  process  is  situated  near  the 
trochanter,  which  may  be  trephined  or  tunnelled  for  the  removal  of  de- 
tritus or  sequestra.^  When  this  is  attempted  for  foci  in  close  proximity 
to  the  hip-joint,  it  excites  increased  reflex  irritability  and  exaggerated 
muscular  spasm,  and  should  in  treatment  be  followed'  by  thorough  trac- 
tion to  overcome  the  injury  following  increased  intra-articular  pressure. 
When  this  cannot  be  provided,  or  when  the  localization  of  the  disease 
is  not  sharply  marked,  the  method  is  of  doubtful  value  in  affections  of 
the  hip-joint  proper. 

The  operation  is  performed  by  exposing  the  part  of  the  bone  in 
which  the  focus  has  been  located  and  removing  it  by  thorough  curet- 
ting. The  cavity  is  then  carefully  dried  and  wiped  out  with  strong  car- 
bolic acid  and  alcohol  or  a  2.5-per-cent  solution  of  formalin,  and  the 
wound  closed,  with  the  exception  of  a  temporary  gauze  wick.  The 
operation  should  be  performed  with  as  little  unnecessary  traumatism  to 
the  joint  as  possible.  The  operation  is  followed  by  traction  in  the  re- 
cumbent position. 

Excision  of  the  Hip- Joint. — This  method  of  treatment  is  based  upon 
the  opinion  that,  when  a  tuberculous  affection  exists,  repair  is  hastened 
by  the  eradication  of  the  diseased  portion.  Excision  is  less  to  be  advo- 
cated at  the  hip  than  at  the  knee  or  ankle,  for  the  reason  that  it  leaves 

'  Feiss :  Journal  of  Med.  Research,  1904. 

-R.  T.  Taylor:  Am.  Journ.  Orth.  Surgery,  vol.  i.,  p.  232. — A.  M.  Phelps: 
N.  Y.  Med.  Journ.,  September  5th,  1900. 


138 


ORTHOPEDIC  SURGERY. 


a  poor  joint  for  weight-bearing  purposes  and  because  it  is  difficult  and 
dangerous  to  remove  the  acetabulum,  frequently  primarily  diseased  in 
hip  disease.  Bardenheuer '  has  excised  the  acetabulum  in  twenty-six 
cases,  eighteen  of  which  were  suffering  from  tuberculous  ostitis  and 
nine  from  osteomyelitis.  He  concludes  as  follows:  that  the  complete 
resection  of  the  hip-joint,  including  the  acetabulum,  is  a  severe  but  not 
fatal  operation,  though  skill  is  required.  It  is  indicated  in  all  cases 
with  septic  involvement  of  the  acetabulum  and  all  cases  of  acetabular 

caries  where  conservative  treatment  has 
failed.  The  operation  is  performed  by 
means  of  an  incision  made  along  the  crest 
of  the  ilium,  extending  from  the  sacro-iliac 
synchondrosis  to  the  anterior  superior  spine. 
The  bone  is  to  be  cleared  of  muscular  at- 
tachments down  to  the  acetabulum.  By 
means  of  a  Gigli  sa\v,  the  acetabulum  is 
separated  from  the  ramus  of  the  pubis,  the 
connection  of  the  ilium,  and  the  descending 
ramus  to  the  tuberosity  of  the  ischium.  It 
is  easier  to  remove  the  acetabulum  without 
opening  the  joint,  which  can  be  opened 
later  and  the  head  of  the  femur  saved.  If 
the  head  of  the  femur  is  involved  it  is  re- 
moved, being  sawn  off  at  the  neck.  The 
wound  should  be  closed  and  traction  applied  to  the  limb,  placed  in  a 
slightly  abducted  position. 

Excision  in  the  early  cases  is  not  justified  when  conservative  treat- 
ment can  be  carried  out  for  a  sufficient  time  and  with  thoroughness. 
The  removal  of  the  head  and  neck,  moreover,  removes  from  the  socket 
one  of  the  supports  on  which  the  trunk  rests,  and  the  hip  is  more 
mutilated  than  after  the  cure  by  the  natural  process  of  gradual  absorp- 
tion, repair,  and  cicatrization,  which  leaves  a  firm  though  possibly  anky- 
losed  hip.  After  excision  the  hip  is  necessarily  mutilated.  The  oper- 
ation is  therefore  reserved  for  the  severer  cases. 

Method  of  Operation. — Of  the  incisions  in  ordinary  use  the  straight 
external  incision  is  the  one  most  commonly  used  and  the  most  service- 
able. 

The  incision  should  begin  at  a  point  midway  between  the  anterior 
superior  iliac  spine  and  the  great  trochanter,  the  knife  being  pushed 
•directly  to  the  bone.  The  cut  should  curve  to  the  top  of  the  trochan- 
ter and  then  downward  and  forward,  the  length  of  the  incision  being 
from  four  to  eight  inches.^ 

'Bardenheuer:  Festschrift  d.  Akad.  f.  prakt.  Med.  in  Coin,  1904. 
2  Brit.  Med.  Jour.,  July  20th,  1889,  p.  119. 


Fig.  136. — Straight  External  In 
cision  for  Excision  of  tin 
Joint. 


TUBERCULOUS  DISEASE   OF   THE  HIP.  139 

The  tissues  should  be  incised  down  to  the  bone,  the  soft  parts 
should  be  divided,  and  the  capsule  opened.  It  is  best  to  incise  the  peri- 
osteum of  the  trochanter,  and  if  possible  with  a  periosteum  elevator 
to  free  it  wdth  its  muscular  attachments  from  the  bone.  Sometimes 
the  whole  trochanter  can  be  uncovered  in  this  way. 

After  having  made  the  cut  down  to  the  trochanter  and  separated 
the  periosteum  on  the  outer  side  so  far  as  practicable,  the  next  step  is 
to  separate  the  soft  tissues  from  the  bone  on  the  inner  side,  stripping 
back  the  periosteum  as  far  as  it  exists  as  such.  In  advanced  cases  of 
hip  disease,  however,  it  will  be  found  that  all  that  it  is  practicable  to  do 
is  to  clear  the  periosteum  from  the  outer  aspect  of  the  trochanter  and 
then  to  separate  the  muscular  attachments  from  the  neck  of  the  bone, 
keeping  the  knife  as  close  to  the  bone  as  possible.  Then  passing  the 
finger  around  the  femur  and  adducting  the  leg  slightly  will  raise  the 
head  of  the  femur  out  of  the  acetabulum,  and  the  capsule  can  then  be 
divided  and  the  head  of  the  femur  thrown  out  into  sight  and  sawed  off, 
or  the  section  can  be  made  by  a  small  saw  or  osteotome  before  dislocat- 
ing the  bone  if  the  finger  is  kept  inside  of  the  neck  of  the  femur  as  a 
guard.  If  the  head  of  the  bone  is  dislocated,  it  is  more  easy  to  see  the 
limit  of  diseased  bone  and  to  make  the  section  well  in  the  healthy  tis- 
sue. The  objection  to  dislocating  the  head  of  the  bone  before  section 
is  that  fracture  of  the  diseased  and  atrophied  shaft  of  the  femur  may 
occur  if  it  is  done  roughly,  and  also  that  periosteum  may  be  stripped  up 
fron.  the  inner  aspect  of  the  shaft  and  cause  necrosis.  When  the  head 
is  adherent,  it  should  be  curetted  or  chiselled  from  its  place. 

The  acetabulum  should  be  examined  and  any  sequestra  removed  and 
any  carious  surface  should  be  scraped  with  a  Volkmann's  spoon.  If 
the  acetabulum  is  perforated,  the  edges  should  be  chipped  off  until  the 
point  is  reached  where  the  periosteum  lining  the  pelvis  is  attached  to 
the  bone. 

After  the  operation  a  tube  or  a  strip  of  gauze  should  be  left  in  the 
most  dependent  angle  of  the  wound  and  the  rest  may  be  sewed  up  if 
the  tissues  are  not  too  much  infiltrated  with  the  products  of  inflamma- 
tion. A  heavy  antiseptic  dressing  should  then  be  applied  and  the  hip 
should  be  fixed  either  upon  a  frame  with  light  traction  or  in  a  plaster- 
of- Paris  spica  with  the  limb  in  an  abducted  position.  As  soon  as  it  is 
practicable  the  child  should  be  allowed  to  move  about  with  crutches, 
wearing,  as  an  appliance  to  prevent  subsequent  deformity,  a  traction 
splint. 

It  is  impossible  to  remove  all  of  the  tuberculous  material  in  excision 
of  the  hip ;  and  this  must  necessarily  lead  to  relapses  and  imperfect 
results  in  many  cases.  The  mere  removal  of  the  head  of  the  bone  is  a 
very  incomplete  measure  for  the  eradication  of  the  disease  in  those 
cases  in  which  the  tuberculous  material  has  mfiltrated  all  the  tissues  m 


I40  ORTHOPEDIC  SURGERY. 

the  neighborhood  of  the  joint.  In  many  cases  of  extensive  disease  it 
is  not  easy  to  do  a  subperiosteal  operation.  In  the  severer  cases  the 
capsule  is  lax  and  partially  destroyed,  so  that  the  finger  when  first 
introduced  in  the  wound  finds  the  head  of  the  bone  only  loosely  in  con- 
tact with  the  acetabulum  and  dislocation  is  easily  accomplished. 

The  ultimate  results  in  cases  in  which  excision  was  performed  only 
after  mechanical  treatment  had  failed  are  as  follows : 

Fer  cent 
Cases,      of  Deaths. 

Children's  Hospital,  Boston,'         .         .         .         .50         44.0 
Hospital  for  Ruptured  and  Crippled,  New  York 

(Townsend  '),  .         .         .         .         .         .99         51.5 

The  causes  of  death  after  excision  of  the  hip  are,  aside  from  the 
small  per  cent  caused  by  the  shock  of  the  operation,  due  to  the  same 
causes  as  in  hip  disease  not  treated  by  excision,  and  it  is  certainly  not 


Fig.  137. — Late   Excision.    Poor  result.    No   motion.     Hip  painful.    Walks  with  splint. 
Three  years  since  operation.     (Children's  Hospital  Report.) 

true,  as  has  been  claimed,  that  excision  of  the  hip  is  a  preventive  of  sys- 
temic infection.  That  general  tuberculosis  and  tuberculous  meningitis 
supervene  in  a  certain  proportion  of  cases  of  hip  disease  is  a  fact  well 
known.  Mr.  Barker,  an  advocate  of  excision,  in  a  lecture  at  the  Royal 
College  of  Surgeons  in  1888  on  the  treatment  of  tuberculous  joint  dis- 
ease, said  that  in  no  less  than  ten  per  cent  of  all  deaths  following  excis- 
ion "  rapid  miliary  tuberculosis  supervened  in  such  a  way  as  to  suggest 
strongly,  if  not  to  prove,  that  the  surgical  interference  was  the  cause 
of  the  generalization  of  the  disease." 

The  statistics  of  Wartmann,  based  upon  837  resections,  show  that 
at  least  10  per  cent  of  all  the  deaths  are  caused  by  rapid  general  miliary 
tuberculosis,  coming  on  in  such  a  way  that  it  is  strongly  suggested  that 
the  surgical  interference  stood  in  a  causative  relation.  This  point  has 
been  of  late  often  alluded  to,  and  the  lesson  to  be  drawn  is  that  in 
excisions  the  work  should  be  done  cleanly,  with  as  little  tearing  of  tis- 
sue and  opening  of  lymphatics  as  may  be,  with  the  most  careful  and 
constant  irrigation. 

'  Orth.  Trans.,  vol.  x. 


TUBERCULOUS  DISEASE   OE   THE  HIP. 


I4[ 


Mortality. — It  may  be  stated  then,  in  brief,  that  resection  of  the  hip- 
joint  as  an  operation  is  attended  by  an  immediate  fatahty  of  about  7 
per  cent.  The  mortality  of  the  disease  after  the  operation  cannot  be 
estimated  as  less  than  20  to  30  per  cent,  and  when  cases  are  followed 
up  for  several  years  it  is  higher  still. 

Functional  Results.— After  excision  of  the  hip-joint  the  mechanical 
conditions  are  not  favorable  to  the  formation  of  a  firm  joint.  After 
operation  the  head  of  the  femur 
is  gone  and  part  or  all  of  the 
neck.  The  capsular  ligament  is 
destroyed,  and  the  upper  end  of 
the  femur  lies  loosely  against  the 
ilium — perhaps  at  the  acetabu- 
lum, perhaps  somewhere  else, 
and  out  of  this  very  uncertain 
contact  a  new  joint  must  be 
formed  if  there  is  to  be  one,  or 
else  a  union  without  motion.  A 
new  joint  is  established  in  suc- 
cessful cases. 

In  these  cases  a  synovial  sac 
may  develop,  and  the  head  of  the 
bone  is  bound  firmly  to  the  ilium 
so  that  a  comparatively  useful 
hip-joint  remains.  But  the  use- 
fulness of  the  limb  after  success- 
ful excision  is  less  than  after 
recovery  under  non-operative 
treatment.  In  some  instances 
a  limb  which  was  in  excellent 
condition  immediately  after  the 
operation  becomes  ultimately  en- 
tirely useless.  An  illustration  of 
this  was  reported  by  one  of  the 
writers  '  in  a  patient  seen  five 
years  after  excision.  In  Cul- 
bertson's  tables"  the  case  is  reported  as  follows:  "(No.  464.) — Re- 
covered in  six  and  two-thirds  months ;  one-half  inch  shortening, 
almost  perfect  motion.  Last  heard  from  six  and  two-thirds  months." 
Though  the  limb  at  the  time  of  the  patient's  reported  condition 
of  cure  was  in  a  favorable  condition,  five  years  later  the  boy  could 
only  touch  the  floor  with  the  toes  of  his  affected  limb,  and  was  unable 

.      '  N.  Y.  Med.  Jour.,  April,  1879. 

'■^Transactions  Am.  Med.  Assn.,  1S76,  p.  142. 


Fig.  138. —Result  of  Suppurative  Hip  Disease 
Treated  by  Traction  after  Three  Years' 
Treatment,  Showing  Extreme  of  Possible 
ilotion. 


142 


ORTHOPEDIC  SURGERY. 


to  walk  without  crutch  or  cane  and  could  bear  little  or  no  weight  on  the 

affected  limb. 

It  is  difficult  to  determine  definitely  how  large  a  proportion  of  useful 

limbs  ultimately  result  in  cases  in  which  recovery  has  taken  place  after 

excision  of  the  hip.' 

In  a  series  of  50  cases  of  excision  of  the  hip  done  at  the  Children's 

Hospital  from  1877  to  1895  it  was  possible  '■'  to  report  on  the  condition 

of  10,  four  years  or  more  after  oper- 
ation. The  interval  ranged  from 
four  to  fourteen  years.  One  had 
his  hip  amputated  later,  a  second 
was  in  poor  general  condition,  but 
with  the  exception  of  the  ampu- 
tated case  no  one  of  the  patients 
used  a  cane  or  crutch ;  one  had  6 
inches  of  shortening,  one  5,  one 
4,  one  had  2  inches,  and  three  had 
only  I  inch.  The  amount  of  mo- 
tion in  flexion  in  those  of  the  10 
cases  in  which  it  was  recorded 
was  as  follows:  None,  25°,  40°, 
45°,6o°,  65°,  80°. 

Indications  for  Excision. — The 
indications  for  excision  can  be 
stated  as  follows : 

1.  When  conservatism  is  im- 
possible owing  to  lack  of  facil- 
ities for  thorough  treatment  and 
the  affection  is  rapidly  progress- 
ive. 

2.  When  a  progressive  destruc- 
tive process  has  continued  in  the 
hip-joint  unarrested  by  the  most 
favorable  conditions. 

3.  When  the  process  is  so 
acute  that  it  threatens  not  only  the  destruction  of  the  joints  but  en- 
dangers life. 

4.  When  an  extensive  sequestrum  is  present. 

It  must  be  borne  in  mind  that  results  as  to  mortality  after  early 
excisions  (before  extensive  destruction  in  the  bone  has  taken  place)  are 

'  Cent.  f.  Chir. ,  1879,  No.  2.  — Med.  Times  and  Gaz. ,  November  3d,  1877.— Orth. 
Trans.,  vol.  vi.,  p.  124. 

-Lovett:  Orth.  Trans.,  vol.  x. 


Fig.  139. — Late  Excision  of  Hip.    Motion  prac- 
tically perfect.     (Same  case  as  Fig.  140.) 


TUBERCULOUS  DISEASE   OE   THE  HIP. 


143 


much  more  favorable  than  after  late  excision.'  The  results  of  careful 
conservative  treatment,  if  carried  out  for  a  long  time,  are  superior  to 
those  after  excision  in  a  majority  of  cases,  and  when  conservative  treat- 
ment is  practicable  it  should  be  preferred.  In  large  hospitals  or  among 
a  poor  and  unintelligent  class,  conservative  treatment  is  sometimes 
impracticable,  and  in  such  cases  excision  is  resorted  to  earlier  than 
would  otherwise  be  justifiable,  and  the  results  gained  are  more  satisfac- 
tory than  when  the  operation  is  deferred.  It  must  be  evident,  in  com- 
paring the  mortality  and  the  results  of  excision  of  the  hip  with  the 


Fig.  140.— Late  Excision  of  Hip.    Motion  practically  perfect. 

mortality  and  the  results  of  conservative  treatment,  that  excision  has 
no  place  in  the  routine  treatment  of  the  disease,  because  its  mortality 
is  higher  and  its  functional  results  are  inferior.  The  operation  has, 
however,  a  decided  usefulness  in  late  cases  of  hip  disease,  when  it 
becomes  distinctly  a  life-saving  procedure,  and  in  severe  cases  at  an 
early  stage  when  no  home  treatment  or  adequate  hospital  treatment  for 
a  long  time  is  practicable. 

'Cent  f.  Chir.,  1894-96.— Congres  de  Chir.,  Proc.  verbale,  4S1. — "  Coxalgie 
Tuberculeuse,"  Paris. — Journ.  de  Med.  et  de  Chir.,  Annales,  iv.,  3,  261. — Congres 
Fr.  de  Chir.,  1S95,  ix. ,  153. — Jalaguier:  These  d'Ag.,  Paris,  18S6. — Archiv  f.  klin. 
Chir.,  xxiv.,  4,  719. 


144  ORTHOPEDIC  SURGERY. 

Although  the  writers  have  been  able  to  gain  thoroughly  satisfactory 
results  after  excision  of  the  hip,  and  in  a  few  instances  have  had  reason 
to  regret  not  having  resorted  earlier  to  excision  in  cases  in  which  con- 
servative treatment  proved  unsatisfactory,  yet  after  years  of  careful 
experience  in  the  treatment  of  hip  disease  by  both  conservative  and 
operative  methods  they  would  unhesitatingly  record  their  opinion  that 
the  conservative  method  of  treatment  is  preferable  to  the  operative  and 
that  resection  is  needed  only  in  exceptional  cases.' 

Amputation. — The  question  of  amputation  of  the  diseased  limb 
alone  remains  for  consideration.  The  mutilation  which  results  is  the 
chief  objection  to  the  operation,  and  is  but  partially  met  by  an  artificial 
limb.  An  undoubted  reformation  of  bone  has  taken  place  in  the  case 
operated  upon  by  one  of  the  writers.'^ 

Absolute  economy  of  blood — of  the  utmost  importance  in  all  hip 
amputations — is  vital  in  cases  reduced  to  the  physical  extremity  seen  in 
cases  of  hip  disease  undergoing  this  operation. 

The  limb  'should  be  elevated  and  stripped  of  blood,  and  an  elastic 
bandage  is  doubled  and  passed  between  the  thighs,  its  centre  lying 
between  the  tuber  ischii  of  the  side  to  be  operated  upon  and  the  anus. 
A  pad  in  the  shape  of  a  roller  bandage  is  tied  over  the  external  iliac 
artery ;  the  ends  of  the  rubber  are  drawn  tightly  upward  and  outward 
(one  in  front  and  one  behind)  to  a  point  above  the  centre  of  the  iliac 
crest  of  the  same  side.  The  front  part  of  the  band  passes  across  the 
compress ;  the  back  part  runs  across  the  great  sciatic  notch  and  pre- 
vents bleeding  from  the  branches  of  the  internal  iliac.  The  ends  of  the 
bandage,  are  tightened,  and  should  be  held  by  the  hand  of  an  assistant 
placed  just  above  the  centre  of  the  iliac  crest. 

The  danger  of  hemorrhage  may  be  still  further  diminished  by  trans- 
fixing the  thigh  from  side  to  side  above  the  line  of  incision  and  securing 
pressure  with  a  steel  skewer  passing  under  the  vessels.  If  rubber  tub- 
ing be  passed  tightly  around  the  ends  of  the  skewer  over  the  anterior 
surface  of  the  thigh,  the  front  vessels  can  be  compressed  and  the  same 
method  can  be  applied  to  the  posterior  vessels  (Wyeth's  method). 
The  operation  in  this  way  can  be  performed  without  the  loss  of  any 
appreciable  amount  of  blood,  and  there  is  time  for  due  deliberation,  as 
there  is  no  danger  of  a  death  upon  the  table  by  a  sudden  gush  of  hem- 
orrhage. 

The  operation  of  amputation  at  the  hip-joint  has  been  performed 
three  times  at  the  Boston  Children's  Hospital  in  extensive  disease  of 

*  E.  H.  Bradford  :  "  Operative  Dislocation  and  Drainage  of  the  Acetabulum  in 
Articular  Disease."     Boston  Med.  and  Surg.  Joum.,  1901,  cxlv.,  240. 

-  Wyeth:  Ann.  of  Surgery,  xxv.,  1897,  127. — Levison :  Jour.  Am.  Med.  Assn., 
June  24th,  1899,  p.  1428. — Erdman:  Ann.  of  Surgery,  September,  1895. — Lancet,- 
May  26th,  1883. 


TUBERCULOUS  DISEASE   OF   THE  HIP.  145 

the  hip  and  pelvis,  with  operative  success  in  all,  but  with  ultimate  death 
from  amyloid  disease  in  two  cases.  Ultimate  recovery  took  place  in 
one  who  grew  to  manhood  and  at  twenty  wore  an  artificial  limb  fitted 
to  a  stump  in  which  reformation  of  the  bone  took  place  from  the  peri- 
osteum. 

The  following  conclusions  would  appear  to  be  justified:  amputation 
at  the  hip-joint,  in  hip  disease,  should  be  regarded  as  the  very  last 
resort,  contraindicated  by  extensive  amyloid  degeneration  of  the  viscera 
or  a  moribund  condition  of  the  patient.  The  chances  of  mortality  are 
not  greater  than  those  in  amputation  of  the  thigh  in  general,  and  the 
chances  of  a  permanent  cure  (barring  the  mutilation)  would  appear  to 
be  greater  than  after  excision  at  the  hip-joint.  The  amputation  should 
be  done  subperiosteally  whenever  it  is  possible. 

Summary  of  Treatment  of  Hip  Disease. 

It  is  difificult  to  summarize  the  treatment  of  hip  disease,  for  the 
reason  that  cases  differ  greatly  in  severity ;  some  needing  recumbency 
for  a  very  long  period,  owing  to  a  severe  degree  of  sensitiveness  or  to 
the  activity  of  the  ostitis,  while  in  other  cases  ambulatory  treatment 
with  proper  appliances  is  sufficient  without  recumbency. 

The  proper  treatment  of  hip  disease  is,  therefore,  not  the  exclusive 
use  of  any  splint,  but  the  use  of  such  means  as  may  meet  the  indica- 
tions as  they  are  present.  During  the  acute  stages,  the  hip-joint  should 
be  fixed  efficiently  in  bed.  This  implies  the  use  of  thorough  traction. 
Continued  confinement  to  bed  is  not  beneficial  to  the  general  condition 
of  tuberculous  patients,  except  temporarily  during  the  acute  stage ;  and 
as  soon  as  the  acute  symptoms  have  subsided  the  patient  should  be 
allowed  to  go  about  with  the  hip  thoroughly  protected  against  jar  and 
spasm.  This  can  be  done  by  means  of  a  traction  splint,  if  efficiently 
applied,  with  at  first  the  additional  protection  from  crutches. 

If  the  acute  symptoms  return  under  this  method,  thorough  rest  in 
bed  is  again  indicated  in  addition  to  efificient  traction  and  fixation.  If 
the  acute  symptoms  diminish  and  there  is  less  muscular  rigidity  at  the 
hip-joint,  greater  freedom  can  again  be  allowed,  and  eventually  traction 
discontinued,  and  the  joint  merely  protected  from  jar.  This  should  be 
continued  so  long  as  there  is  any  danger  of  recurrence  of  active  symp- 
toms or  tendency  to  contraction. 

In  brief,  the  hip  should  be  fixed  as  long  as  it  is  sensitive,  should  be 
protected  and  distracted  as  long  as  there  is  muscular  spasm,  and  pro- 
tected as  long  as  it  is  weak.  The  best  results  are  attained  only  by 
thorough  treatment  for  a  year  at  least,  and  careful  supervision  and 
protection  for  two  or  three  subsequent  years.  Distortions  of  the  limb 
should  always  be  corrected  as  they  occur.  In  many  cases  some  motion 
can  be  saved  at  the  hip-joint  if  treatment  is  not  discontinued  too  soon. 


146  ORTHOPEDIC  SURGERY. 

Abscesses  can  be  treated  on  general  surgical  principles.  Radical 
operative  measures  are  needed  only  in  exceptional  cases  if  thorough 
conservative  treatment  can  be  secured.  Out-of-door  air,  the  best  ob- 
tainable surroundings,  with  as  much  activity  as  the  local  conditions  of 
the  joint  justify,  stimulating  the  circulation  by  exercise,  and  improving 
the  appetite  and  the  metabolism,  are  the  antidotes  at  present  available 
to  the  tuberculous  condition.  These,  if  combined  with  such  surgical 
treatment  as  will  protect  the  affected  bone  from  frequent  traumatism, 
may  be  relied  upon  to  effect  a  cure  in  the  greater  number  of  cases  of 
hip  disease. 


CHAPTER    IV. 
TUBERCULOUS    DISEASE    OF    THE    KNEE. 

Definition.— Pathology. — Clinical  history. — Diagnosis. — Differential  diagnosis. — 
Prognosis. — Treatment,  (a)  conservative,  (d)  operative  (excision,— arthrectomy, 
— amputation). 

DEFINITION. 

The  other  names  by  which  this  affection  is  known  are  tumor  albus^ 
white  swelhng,  scrofulous  disease  of  the  knee,  chronic  purulent  or  fun- 
gous synovitis  of  the  knee,  etc. 

The  knee-joint  differs  in  anatomical  structure  from  the  hip,  in  that 
the  joint  surfaces  forming  the  knee  are  nearly  flat  and  the  facets  in  the 
tibia  shallow.  Owing  to  this  fact,  the  tibia  is  easily  drawn  backward 
and  flexed  by  the  hamstring  muscles,  the  flexors  of  the  leg  being 
much  stronger  than  the  extensors ;  at  the  same  time  it  is  rotated  out- 
ward, the  combination  constituting  the  common  and  troublesome  de- 
formity which  is  the  characteristic  one  after  severe  tumor  albus. 

The  course  of  the  disease  in  the  knee  does  not  differ  in  general  from 
that  in  the  hip,  but  the  measures  necessary  for  preventing  deformity  in 
the  two  joints  are  somewhat  different. 

PATHOLOGY. 

Tumor  albus,  as  it  is  seen  in  children,  begins  oftenest,  if  not  always, 
as  an  epiphyseal  ostitis  of  the  tuberculous  type.  Like  other  forms  of 
tuberculous  disease,  it  is  oftenest  limited  to  certain  portions  of  the 
epiphysis,  and  either  the  femoral  or  tibial  epiphysis  may  be  attacked 
primarily.  Cases  are  occasionally  seen,  however,  in  which  the  primary 
focus  is  in  the  patella  or  in  the  head  of  the  fibula.  Li  children  it  is  not 
uncommon  to  see  an  acute,  apparently  traumatic  effusion  gradually 
absorbed,  leaving  an  infiltrated  and  thickened  synovial  sac.  In  the 
greater  number  of  cases,  however,  the  bone  symptoms  clearly  precede 
the  effusion. 

The  pathological  appearances  of  tuberculous  joints  have  been  so 
fully  described  in  speaking  of  the  pathology  (Chapter  L)  that  it  is  not 
worth  while  to  enter  upon  them  here  to  any  extent. 

In  the  severer  cases  a  destructive,  fungous,  or  purulent  synovitis 

147 


148 


ORTHOPEDIC  SURGERY. 


generally  develops,  which  becomes  the  characteristic  feature  of  the 
process.  This  may  end  in  a  complete  destruction  of  the  joint  or  in 
arrest  and  recovery  by  absorption  and  cicatrization. 

CLINICAL    HISTORY. 


The  affection  begins,  as  a  rule,  insidiously,  with  stiffness  and  limp 
in  gait.     The  disease  may  be  limited  for  a  long  time,  and  be  manifested 

by  an  enlargement  of  the  con- 
dyles or  head  of  the  tibia,  or 
it  may  extend  and  involve  the 
whole  joint;  occasioning  severe 
pain,  swelling  of  the  periarticu- 
lar tissues,  effusion  into  the 
joint,  periarticular  abscess,  and 
distortion  of  the  limb  {i.e.,  flex- 
ion and  subluxation),  and  end- 
ing in  a  natural  cure  with  fibrous 
or  bony  ankylosis  and  a  distorted 
limb,  which  may  be  more  or  less 
serviceable,  according  to  the 
distortion;  or  the  affection -may 
result  in  such  extensive  sup- 
puration as  to  endanger  life 
from  septic  or  amyloid  changes. 
Sometimes  in  cases  of  moderate 
severity  an  attack  of  severe 
pain  supervenes,  and  an  acute 
stage  is  reached,  when  the  limb 
is  flexed  at  the  knee,  hot  and 
tender  to  the  touch,  and  sen- 
sitive to  any  jar.  Under  proper 
treatment  this  stage  gradually 
subsides,  and  there  may  be  left 
impairment  of  motion.  En- 
largement of  the  bone,  if  it 
persists  for  any  length  of  time, 
is  characteristic  of  chronic  epiphysitis  of  the  knee. 

In  the  milder  cases,  arrest  of  the  disease  may  occur  at  any  time  with 
more  or  less  complete  restoration  of  the  joint.  In  the  severer  cases 
suppuration  may  follow,  with  the  establishment  of  sinuses.  The  de- 
structive process  may  become  so  extensive  that  excision  or  amputation 
is  required.  In  general,  the  affection  is  favorably  affected  by  proper 
treatment. 


Fig.  141. — Tumor  Albus.  Joint  shows  general 
tuberculous  process,  without  visible  connec- 
tion with  the  primary  focus ;  a  cavity  in  head 
of  tibia  of  three  centimetres  diameter,  filled 
with  cheesy  material,  a,  Tuberculous  focus 
m  femur.     (Xichols.) 


TUBERCULOUS  DISEASE   OF   THE  KNEE. 


149 


In  tumor  albus  the  most  noticeable  symptoms  are  heat,  swelling, 
tenderness,  and  joint  distention ;  while  in  hip  disease,  the  joint  being 
less  accessible,  a  different  class  of  symptoms,  restriction  of  motion, 
limp,  and  distortions  of  the  limb,  are  more  to  be  depended  upon. 


Fig.  142.— Right  Knee-joint  Bent.  Sagittal  section.  Joint  surface  slightly  separated,  show- 
ing the  infra-patellar  fat  pad,  and  the  bursa  under  the  patella  tendon  as  well  as  the  ex- 
tent of  the  joint  synovial  membrane.     (Fick.) 

Swelling. — In  tumor  albus  the  knee  will  be  seen  to  have  lost  its  defi- 
nite contour,  the  depressions  on  the  sides  of  the  patella  have  become 
filled  out  so  that  there  is  an  indistinctness  of  outline  which  is  as  per- 
ceptible to  the  touch  as  to  the  sight.  Most  often  the  patella  seems  to 
be  raised  from  its  position  by  a  semi-solid  mass  and  the  whole  knee 


I50 


ORTHOPEDIC  SURGERY. 


seems  surrounded  by  a  boggy  infiltration.  Later  it  assumes  a  spindle 
shape  and  the  distention  causes  the  skin  to  be  somewhat  anaemic  in  the 
more  severe  cases,  whence  the  name  of  tumor  albus. 

The  swelling  at  the  knee,  unless  suppurative  synovitis  is  present  to 
a  marked  degree,  differs  from  that  of  synovitis  with  effusion,  in  that  the 
swelling  is  of  the  bone  and  soft  periarticular  tissues,  and  is  not  alto- 
gether within  the  joint.  If  the 
effusion  is  large,  as  in  chronic 
serous  synovitis,  the  patella, 
when  the  muscles  holding  it  are 
relaxed,  can  be  depressed  by 
pressing  on  it,  and  be  felt  to  hit 
against  the  bone  as  it  floats 
above  the  fluid  within  the  joint. 
In  effusion  the  shape  of  the 
swelling  is  characteristic.  When 
effusion  is  the  characteristic  feat- 
ure, it  is  most  prominent  on  both 
sides  of  the  patella,  and  is  lim- 
ited by  the  tendon  of  the  quadri- 
ceps extensor  muscle  and  by  the 
ligamentum  patellae. 

In  some  instances,  one  of  the 
condyles — usually  the  internal 
condyle — is  enlarged  more  than 
the  other,  causing  knock-knee. 

Atrophy. — Atrophy  of  the 
muscles,  both  of  the  thigh  and 
calf,  is  present,  and  reaches  a  seri- 
ous degree  inacute  cases.  It  is 
more  equally  distributed  between 
the  muscles  of  the  thigh  and  those 
of  the  leg  than  in  hip  disease. 

Shortening. — Shortening  is  a 
much  less  important  factor  than 
in  hip  disease,  and  until  late  in  the  affection  does  not  appear  to  any  extent, 
and  this  late  shortening  comes  as  a  result  of  the  faster  growth  of  the  well 
leg  oftener  than  as  the  out  come  of  bone  destruction.  During  the  course 
of  the  disease  kngthoiing  of  the  affected  leg  may  occur.  The  hyper- 
aemia  occasioned  by  the  inflammation  induces  the  overgrowth  in  all 
directions  of  the  tibial  and  femoral  epiphyses,  so  that  they  outstrip  for 
a  while  those  of  the  other  leg.  In  measuring  a  child  with  tumor  albus 
it  is,  therefore,  not  uncommon  to  find  the  diseased  leg  half  an  inch 
longer  than  the  other.     Later  in  the  disease,  the  trophic  disturbance 


Fig.  143. — Tuberculous  Knee  in  Adult.  Gen- 
eral synovial  tuberculosis.  Large  irreg'ular 
area  of  tuberculous  softening  in  epiph^-seal 
end  of  femur,  extending-  into  joint  along 
crucial  ligaments.     (Nichols.) 


TUBERCULOUS  DISEASE   OF   THE  KNEE. 


I  ;i 


which  occurs  in  all  these  tuberculous  joint  affections  makes  itself  felt 
and  the  diseased  leg  falls  behind  the  well  one  in  its  growth. 

Pain. — The  pain  of  the  affection  is,  except  during  the  acute  exacer- 
bations, not  severe,  though  pain  on  jarring  the  limb  is  common.  Night 
cries  are  much  less  common  than  in  hip  disease,  but  they  occur. 
When,  however,  the  patient  does  suffer  from  an  acute  exacerbation,  the 
pain  and  tenderness  are  excessive.     From  the  exposed  condition  of  the 


d— 


Fig.  144.— Tuberculous  Knee,  Process  of  Repair  Advanced.     Small   focus  persists,     a,  Tibia  ; 
5,  tuberculous  softening  ;  c,  femur  ;  d,  patella.     fNichols  ) 

joint  jars  and  twists  are  very  common,  and  the  suffering  may  be  ex- 
treme. Tenderness  is  very  common,  especially  over  the  inner  surface  of 
the  head  of  the  tibia.  In  certain  cases,  however,  the  knee  is  held  rigid 
by  muscular  spasm,  and  any  reasonable  manipulation  fails  to  occasion 
any  pain. 

Heat. — Heat  of  the  affected  joint  is  present  and  is  a  most  valuable 
index  of  the  progress  of  a  case.  It  can  be  easily  felt  with  the  hand  as 
long  as  the  disease  is  active,  but  when  it  becomes  quiescent  it  disappears, 
to  return  if  anything  goes  wrong.    It  can  be  felt  to  diminish  if  treatment 


152 


ORTHOPEDIC  SURGERY. 


is  successful  in  quieting  the  condition  of  the  joint,  and  is  a  most  urgent 
indication  for  protective  treatment  so  long  as  it  exists  in  any  degree. 

Lameness. — Lameness  is  a  constant  symptom.  It  varies  with  the 
sensitiveness  of  the  joint  and  is  much  influenced  by  the  amount  of  flexion 
present  in  the  diseased  knee. 

Muscular  Fixation. — Muscular  fixation  is  a  symptom  of  this  as  of  all 
chronic  tuberculous  ostitis,  but  is  less  prominent  than  in  the  hip.     In 

the  early  stages  it  may  be 
practically  absent.  The  joint 
may  be  held  perfectly  rigid 
in  full  extension  or  in  partial 
flexion,  or  a  certain  arc  of  mo- 
tion may  be  permitted,  and 
then  the  muscles  quickly 
catch  the  joint  and  prevent  it 
from  going  farther.  Persis- 
tent muscular  spasm  results 
in  the  characteristic  malposi- 
tions of  the  affection :  flexion, 
and  subluxation  of  the  tibia. 
Deformity. — Malpositiojis 
of  the  limb  result  from  the 
greater  power  the  flexor  mus- 
cles of  the  thigh  possess  in 
contrast  to  the  extensors. 
The  limb  becomes  gradually 
flexed  almost  from  the  first, 
and  if  the  affection  goes  on 
without  treatment,  flexion 
may  reach  a  right  angle,  and 
this  is  the  tendency  of  the 
disease  throughout  and  a 
marked  obstacle  to  its  suc- 
cessful treatment. 

Even  when  the  affection 
is  nearly  cured  or  after  a 
slight  injury  of  the  joint 
flexion  may  return,  which  is 
accompanied  by  increased  heat  and  tenderness.  Together  with  the 
flexion,  and  as  a  result  also  of  the  predominance  of  the  flexor 
muscles  of  the  thigh,  subluxation  of  the  tibia  backward  occurs  at  a 
later  stage  of  the  affection;  this  is  due  to  the  shape  of  the  joint  sur- 
faces and  the  persistent  contraction  of  the  hamstring  muscles  always 
pulling  the  tibia  backward.     If  the  leg  has  assumed  this  distortion 


Fig.  145.— Bony  Ankylosis  of   the  Knee-joint,  with 
Ankvlosis  of  Patella. 


TUBERCULOUS  DISEASE   OF   THE  KNEE. 


153 


and  is  straightened  without  an  attempt  to  correct  the  subluxation,  the 
tibia  will  lie  in  a  plane  back  of  that  of  the  femur,  and  the  part  of  the 
knee  formed  by  the  femur  and  patella  will  be  unduly  prominent. 


Fig.  146. — Subluxation  in  Tumor  Albus. 


Another  result  of  long-continued  muscular  spasm  is  the  external 
rotation  of  the  tibia  upon  the  femur,  which  accompanies  severe  grades 
of  flexion  and  persists  after  straightening  of  the  leg  if  such  is  accom- 


FiG.  147.— Position  of  Deformity  in  Tumor  Albus. 

plished.     In  the  same  way  a  certain  amount  of  knock-knee  is  apt  to  be 
present  in  the  corrected  limb  after  severe  grades  of  tumor  albus. 

Abscess. — Abscess  appears  either  as  a  purulent  distention  of  the  cap- 


154 


ORTHOPEDIC  SURGERY. 


sule,  which  ma)'  point  at  any  part  of  the  surface  and  discharge  by  sinuses 
for  an  indefinite  time,  or  abscesses  form  in  the  periarticular  tissues  as 
in  hip  disease.  As  a  rule  abscess  formation  is  accompanied  by  an  acute 
degree  of  the  affection. 

DIAGNOSIS. 

The  diagnostic  symptoms  and  signs  in  tumor  albus  are  an  intermit- 
tent lameness;  a  general  enlargement  of  the  knee-joint,  with  a  feeling 

of  stiffness  and  pain  on  using  the  limb ; 
heat  over  the  joint;  and  the  presence 
of  local  tenderness  and  muscular  stiff- 
ness in  manipulation  of  the  joint. 

The  character  of  the  enlargement  of 
the  knee-joint  is  of  great  importance. 

DIFFERENTIAL    DIAGNOSIS. 

Gross  errors  in  diagnosis  in  affec- 
tions of  the  knee  are  not  common,  as  a 
thorough  examination  of  the  joint  is 
readily  made.  The  distinction  between 
a  synovitis  with  effusion  and  a  chronic 
ostitis  is  based  on  the  size  and  shape  of 
the  swelling.  The  diagnosis  is  often 
aided  by  an  A'-ray  examination.  By 
the  test  of  aspiration  and  guinea-pig 
inoculation,  a  diagnosis  can  be  estab- 
lished. 

Synovitis. — Sluggish  cases  of  syno- 
vitis in  young  children  should  be  re- 
garded with  very  great  suspicion,  inas- 
much as  they  are  likely  to  eventuate 
in  tumor  albus  at  any  time,  if  the  con- 
dition is  not  already  that. 

Periarticular  Disease — Periarticular 
disease  (inflammation  of  bursse  and 
periarticular  abscesses)  is  to  be  distin- 
guished from  true  articular  disease  in 
that  there  is  little  or  no  joint  stiffness, 
and  in  that  the  swelling,  if  present, 
does  not  bear  the  relation  to  the  patella 
that  occurs  when  there  is  fluid  beneath  the  patella ;  the  distention  be- 
ing clearly  outside  of  the  joint  sac. 

Functional  disease  (hysterical,  neuromimetic)  of  the  knee  is  to  be 
recognized  by  the  absence  of  objective  symptoms  and  the  prominence 


Fig.  148. — Tuberculosis  of  Right  Knee- 
joint,  with  Marked  Bony  Enlarge- 
ment at  Inner  Side  of  Knee. 


TUBERCULOUS  DISEASE   OF   THE  KNEE.  155 

of  subjective  symptoms.  Heat  is  generall}-  absent,  limitation  of  motion 
and  tenderness  may  be  excessive,  and  swelling'  and  alteration  of  the 
joint  contour  are  absent. 

Arthritis  Deformans. — A  diagnosis  between  a  tuberculous  affection 


Fig.  149.  — Severe  Tuberculosis  of  Knee-joint  with  Marked  Swelling-,  Flexion,  and  Sinus. 

and  that  form  of  arthritis  deformans  with  synovial  infiltration  and 
change  is  difficult  and  can  often  be  made  only  by  a  careful  study  of  the 
case  with   the  aid  of   the  inoculation  test.     It  is  to  be  remembered 


Fio.  150. — Tuberculosis  of  Knee-joint  with  Extreme  Flexion  Deformity. 

that  tuberculous  disease  is  more  common  in  childhood  than  is  arthritis 
deformans. 

Haemophilia  may  cause  an  inflammation  of  the  knee  closely  resem- 
bling tumor  albus.  The  diagnosis  must  be  made  by  establishing  the 
existence  of  the  bleeder's  diathesis  and  by  the  course  of  the  case. 


156  ORTHOPEDIC  SURGERY. 

PROGNOSIS. 

Tke  prognosis  of  tumor  albus  is  similar  to  that  of  the  same  affec- 
tions of  the  other  large  joints.  The  functional  results  after  conserva- 
tive treatment  are  in  av' erage  cases  excellent ;  sometimes  perfect  motion 
is  restored,  but  in  general  only  an  incomplete  arc  remains  with  occa- 
sionally complete  rigidity.  The  earlier  that  treatment  is  begun  and  the 
more  faithfully  it  is  carried  out,  the  better  is  the  outlook  as  to  functional 
result.  In  advanced  cases  disability  necessarily  follows,  and  in  neglected 
cases  deformity  of  the  limb,  flexion  at  the  knee,  subluxation  of  the  tibia, 
and  the  formation  and  discharge  of  abscesses  are  likely  to  occur,  ending 


Fig.  151. — Old  Tumor  Albus  Recovered,  Showing  Degree  of  Possible  Flexion. 

either  in  a  complete  destruction  of  the  joint  or  in  a  cure  with  ankylosis. 
A  liability  of  the  dissemination  of  the  tuberculous  disease  to  the  brain 
or  lungs  exists  in  this  as  in  other  similar  affections. 

In  all  severe  cases  there  is  a  danger  of  permanent  distortion  of  the 
limb.  This  may  be  so  severe  as  to  render  the  limb  useless.  Flexion  of 
the  limb  is  a  constant  result  in  severe  cases  unless  treated  with  great 
care.  Shortening  is  less  likely  to  exist  to  a  troublesome  extent  than  in 
hip  disease. 

As  in  all  cases  of  epiphyseal  ostitis  of  the  larger  joints,  the  progno- 
sis as  to  the  tmie  of  requisite  treatmen.t  depends  not  only  on  the  time 
needed  to  check  the  inflammation,  but  also  for  the  re-establishment  of 
sound  bone  tissue  capable  of  bearing  weight  without  danger  of  relapse. 
This  in  growing  children  demands  a  long  time.     Protection  is  generally 


TUBERCULOUS  DISEASE   OE   THE  KNEE.  I57 

necessary  for  from  one  to  two  years,  and  perhaps  even  longer,  after  the 
acute  stage  is  ended. 

TREATMENT. 
The  treatment  may  be  classed  as  conservative  and  operative. 

Conservative  Treatment  of  Tumor  Aldus. 
What  was  said  in  regard  to  the  treatment  of  hip  disease  may  be 


Fig.  152.— Old  Tumor  Albus  Recovered  with  Motion,  Showing'  Subluxation  of  Tibia. 

repeated  in  speaking  of  epiphysitis  of  the  knee-joint.  The  treatment 
should  be  thorough  and  persistent,  and  should  meet  the  indications,  and 
fixation  and  protection  are  the  most  important  indications  in  diseases  of 
the  knee,  while  traction  is  less  so.  The  employment  of  protection 
should  be  continued  until  it  is  probable  that  the  epiphysis  is  normal, 
which  is  a  matter  of  judgment  in  every  case.  Protection  should  be  dis- 
continued gradually  and  tentatively ;  if  discontinued  too  soon,  recur- 
rence will  take  place,  or  the  deformity  of  the  limb  will  increase.  Fixation 
should  be  used  so  long  as  there  is  any  activity  of  the  inflammation ;  this  is 


158 


ORTHOPEDIC  SURGERY. 


indicated  by  pain,  muscular  spasm,  or  tenderness.  Efficient  fixation  of 
the  knee  does  not  require  confinement  to  bed  except  in  ver}'  acute  cases, 
in  abscess,  and  in  deformity. 

In  cases  in  the  acutest  stage  the  patient  is  kept  in  bed  with  the  hmb 
hekl  by  weight  and  pulley  traction  and  the  foot  and  limb  steadied  by 
sand  bags  or  side  splints  or  by  a  splint  plaster  bandage.  Ordinarily 
this  acute  stage  is  absent  or  is  brief,  and  ambulatory  treatment  is  both 
possible  and  desirable. 

Fixation.— It  is  manifest  that  the  most  thorough  fixation  is  made  if 
the  fixing  appliance  is  as  long  and  extends  as  high  as  possible.     The 

leg  and  femur,  if  much  longer 
than  the  appliance,  will  have 
a  greater  mechanical  advantage 
than  if  the  splints  are  suffi- 
ciently long.  It  should  also  be 
borne  in  mind  that,  owing  to 
the  fact  that  the  thigh  is  well 
covered  by  soft  tissues,  a  cer- 
tain amount  of  motion  is  pos- 
sible owing  to  the  yielding  of 
the  soft  parts.  Fixation  by  stiff 
bandages  is  an  efficient  method 
of  treatment  when  the  bandages 
are  properly  applied.  They 
should  reach  from  the  groin  to 
the  ankle,  in  the  acute  cases  in- 
cluding the  foot,  and  as  firmly 
as  possible  grasp  the  muscles  of 
the  limb.  Plaster  of  Paris  is  the 
most  available  material  for  use. 
The  method  does  not  give  in 
all  cases  certain,  definite  sup- 
port. Judson  says  in  regard  to 
it :  "It  may  be  an  exaggeration, 
but  it  conveys  the  idea,  to  say 
that  a  plaster-of-Paris  or  silicate 
splint,  applied  to  the  leg  and  thigh,  contains  a  mass  of  jelly  in  which 
the  femur  is  but  little  restrained  from  motion."  And  in  a  degree  this 
is  true  of  all  stiff  bandages. 

The  figure  shows  the  inefficiency  of  a  loosel)'  applied  plaster  band- 
age so  far  as  fixation  is  concerned.  Other  stiff  bandages  are  of  silicate 
of  potash,  leather,  celluloid,  wood  pulp,  papier  mache,  etc.  The}-  may 
be  cut  down  the  front  and  laced  so  as  to  be  removed  at  any  time.  Fix- 
ation without  protection  is  inadec|uate  treatment  when  locomotion  is 


Fig.  15 


-Tuberculosis  of    Knee-ioint  with 
Abscess. 


TUBERCULOUS  DISEASE  OF   THE  KNEE. 


•59 


desired.  For  this  reason  it  is  insufficient  to  apply  a  stiff  splint  to  the 
affected  leg  and  to  allow  the  patient  to  walk  without  further  protection 
of  the  limb. 

Fixation  as  a  means  of  treatment  so  far  has  been  considered  only 
as  applicable  to  the  limb  in  its  straight  position.     Much  more  often  a 


Fig. 


-Radiograph  of  Old  Tuberculosis  of  Knee-joint,  Showing  Destruction  of  Joint  Sur- 
faces and  Bone,  Flexion  and  Subluxation  of  Tibia. 


degree  of  flexion  is  present  to  complicate  matters,  the  treatment  of 
which  will  be  considered  later. 

Protection. — Protection  can  be  furnished  by  means  of  crutches  and 
raising  the  sound  limb  by  a  thick  sole  which  allows  the  affected  limb  to 
swing  clear  of  the  ground.  Better  protection  is  furnished  by  means  of 
a  splint  with  perineal  support  and  longer  than  the  limb,  which  passes 
below  the  foot  so  as  to  take  the  jar  of  locomotion.  The  best  of  these 
splints  is  one  similar  to  that  already  described  as  a  protective  splint  in 
hip  disease.  It  will  be  described  more  fully  in  speaking  of  the  treat- 
ment of  flexion  in  tumor  albus. 

Thomas  Knee  Splint. — A  simple  appliance  is  the  Thomas  knee  splint 


i6o 


ORTHOPEDIC  SURGERY. 


(Chapter  XXL,  14)  which  consists  of  a  padded  iron  ring  fitted  so  as  to 
surround  the  thigh  at  the  perineum,  and  fastened  to  two  rods  on  each 
side  of  the  Hmb,  longer  than  the  hmb  and  secured  at  the  bottom  to  a 
metal  plate  below  the  foot  or  bent  to  fit  into  a  slot  under  the  shank  of 
the  boot. 

The  bar  at  the  bottom  of  the  splint  can  be  utilized  as  a  means  for 
using  traction  if  adhesive  plaster  is  applied  to  the  leg  and  webbing 
sewn  to  the  lower  ends;  the  webbing  straps  are  buckled  tightly  around 
the  bar,  and  a  certain  amount  of  traction  can  be  exerted.     The  idea  of 


Pig. 


5.— Imperfect  Fixation  of  Knee-joint 
by  Loose  Plaster  Bandage. 


Fig.  156. — Imperfect  Fixation  of  Knee-joint 
by  Plaster  Bandage  of  Improper  Length. 


using  traction  is  not  in  accordance  with  the  views  of  the  inventor  of 
the  splint.  The  leg  can  be  fixed  by  means  of  bandages  and  leather 
bands  attached  to  the  splint.  With  this  splint  applied,  the  patient  sits 
in  a  ring  supporting  the  perineum,  while  uprights  run  below  the  foot  and 
bear  the  body  weight. 

In  cases  requiring  less  rigid  protection  and  in  the  case  of  adults  the 
inner  half  of  the  perineal  ring  is  cut  away  and  from  the  two  extremities 
of  the  cut  ring  is  slung  a  leather  perineal  band  on  which  the  patient 
rests  in  the  same  manner  as  in  a  hip  splint. 

In  acute  cases  and  cases  tending  to  flexion  the  use  of  a  plaster-of- 
Paris  splint  in  addition  to  the  Thomas  splint  is  desirable,  as  better  fixa- 
tion is  secured  than  by  bandages.     Traction  is  necessary  only  in  very 


TUBERCULOUS  DISEASE   OF   THE  KNEE. 


i6i 


acute  cases ;  a  stiff  bandage  to  the  knee  in  addition  to  the  Thomas  splint 
contributes  better  fixation  than  is  possible  with  the  splint  alone. 

The  Thomas  splint  is  slung  from  the  shoulder  by  means  of  a  strap, 
and  the  well  limb  is  raised  by  means  of  a  cork,  wooden,  or  steel  patten. 
Crutches  are  not  necessary  in  connection  with  the  Thomas  splint. 

Calliper  Splint.— When  the  condition  of  the  limb  has  improved  so 
much  that  spasm  and  sensitiveness  are  absent  or  in  mild  cases  the 
Thomas  splint  (Chapter  XXI.,  15)  can  be  shortened  and  the  ends 
slotted  into  the  sole  of  the  shoe  at  such  a  place  that  the  splint  is  too 
long  for  the  heel  to  touch  the  ground,  and  in  this  way  the  patient  walks 
about  suspended  largely  by  the  perineal  ring  and  bearing  but  little 


Fig.  157.— Wire  Splint  for  Gradual  Correction  of  Knee  Flexion. 


weight  on  the  diseased  joint.     Then  gradually  after  some  months  the 
use  of  the  splint  may  be  discontinued. 

When  convalescence  has  been  further  established  and  protected 
motion  at  the  joint  is  possible,  the  knee  splint  may  be  jointed  with  a 
spring  catch  and  check  to  limit  the  amount  of  motion. 

Blisters,  cauterization,  and  counter-irritation  are  beneficial  only  in 
relieving  the  symptoms  of  pain  temporarily. 

The  treatment  by  passive  hyperaemia  and  dry  heat  is  useful  if  at  all 
in  the  milder  and  more  chronic  cases. 

•    Treatment  of  Complications.— Z>£/(?;'w//j'. — Flexion  of  the  knee  is 
commonly  seen  even  in  the  early  stage  of  the  affection,  associated  in 
the  early  part  of  the  disease  with  an  acutely  sensitive  condition  of  the 
1 1 


l62 


ORTHOPEDIC  SURGERY. 


joint,  but  later  in  the  history  it  may  come  on  insidiously  and  without 
pain. 

The  means  of  straightening  a  knee-joint  flexed  by  acute  disease  may 
be  classified  as  follows : 

I.  By  traction  in  the  line  of  the  deformity  applied  {a)  in  bed;  {U) 
while  the  patient  goes  about. 

2    By  simple  fixation  by  means  of  a  succession  of  plaster-of-Paris 
bandages. 

3.  By  straightening  under  ether. 

I  («).  In  sensitive  cases  it  may  be  necessary  to  confine  the  patient 
to  bed.  Traction  by  weight  and  pulley  can  be  applied  to  the  leg  by 
means  of  adhesive  plaster  applied  below  the  knee, 
the  leg  being  supported  by  a  firm  cushion  under 
the  knee  arranged  so  that  traction  comes  in  the 
line  of  the  deformity.  After  a  diminution  of  the 
spasm,  which  follows  very  soon  upon  the  appli- 
cation of  traction,  the  limb  can  be  made  straight 
gradually  and  fixed  in  a  straightened  position,  and 
ambulatory  treatment  can  be  begun. 
)^  I  ib').   Traction  in  the  line  of  the  defoi'viity 

'J  can  be  applied   to   the   limb   while   the  patient 

goes  about,  by  one  of  several  appliances  which 
are  more  or  less  expensive.  The  best  splint  is 
one  already  alluded  to,  similar  to  the  protection 
splint  described  for  hip  disease  (Chapter  XXI., 
16).'  It  is  furnished  with  a  perineal  band  which 
takes  the  body  weight  off  of  the  leg,  and  at  the 
knee  is  a  lock  joint  which  can  be  set  at  any  angle. 
The  bottom  of  the  splint  goes  far  enough  below 
the  foot  to  protect  the  limb  from  jar  in  walking, 
and  ends  in  a  traction  bar.  The  splint  is  set  at 
an  angle  corresponding  to  the  angular  deformity 
of  the  affected  knee,  and  traction  is  made  up- 
ward above  the  knee  by  means  of  adhesive  plaster 
attached  to  the  thigh  and  buckling  on  to  the 
splint,  and  extension  is  made  downward  below 
the  knee  by  a  plaster  extension  pulling  down 
to  the  traction  bar  at  the  bottom  of  the  splint. 
The  leg  is  fixed  in  the  splint  by  leather  lacings  for  the  thighs  and  calf, 
which  are  adjusted  after  the  extension  is  tightened.  A  simpler  appa- 
ratus has  been  described,"  made  of  plaster  of  Paris  and  serving  the  same 
purpose  except  that  it  does  not  allow  weight  bearing  on  the  affected  leg. 


Fig.  158. —Thomas  Cal- 
liper Splint,  with  Pads, 
Applied.  (Ridlon  and 
Jones  ) 


Lovett :  Orth.  Trans.,  vol.  v 
H.  L.  Taylor:  Orth.  Trans. 


vol. 


P-  53- 


TUBERCULOUS  DISEASE   OF   THE  KNEE.  163 

2.  Rcdiictioji  of  Flexion  by  Fixation  Bandages. — A  very  simple  way 
to  straighten  a  knee-joint  acutely  flexed  by  disease,  when  apparatus 
cannot  be  afforded  or  is  impracticable,  is  by  simple  fixation  of  the  knee- 
joint  by  means  of  a  series  of  plaster-of-Paris  bandages.  These  should 
be  applied  to  the  knee  in  its  deformed  position  without  any  attempt  to 
extend  it.  It  will  be  often  found  in  the  lighter  cases  that  the  limb  can 
be  made  straighter  at  each  successive  bandage,  so  great  is  the  sedative 
action  of  complete  fixation.  It  is  hardly  necessary  to  add  that  no 
weight  should  be  borne  upon  the  limb  during  the  process  of  straighten- 
ing. 

3.  Forcible  Reduction  of  Flexion. — In  cases  without  adhesions  the 
knee  is  easily  put  in  a  correct  position  with  the  use  of  little  or  no  force 


Fig.  159.— Reduction  of  Flexion  Deformity  by  Traction  in  Recumbenc}\ 

under  complete  anaesthesia.  If  the  leg  is  allowed  to  remain  in  the 
flexed  position,  angular  ankylosis  will  probably  occur,  as  shown  in  the 
figures.  When  firm  adhesions  have  been  formed  at  the  knee-joint,  cor- 
rection by  means  of  appliances  will  be  found  tedious,  painful,  and  some- 
times impossible,  and  generally  forcible  correction  of  some  sort  will  be 
necessary  to  break  down  the  adhesions.  One  way  is  to  break  down  the 
adhesions  by  forcibly  flexing  the  leg,  and  then  by  forcible  extension  to 
straighten  it.  The  danger  of  rupturing  the  popliteal  artery,  which  has 
occurred,  is  in  this  way  diminished.  Many  appliances  have  been 
devised  to  give  greater  power  in  forcible  correction.  One  procedure 
not  requiring  the  use  of  apparatus  is  as  follows :  The  patient  is  placed 
upon  the  floor  upon  the  back  and  the  surgeon  stands  over  the  patient, 
holding  the  flexed  knee  with  both  hands,  the  fingers    being  placed 


164 


ORTHOPEDIC  SURGERY. 


under  the  popliteal  space.  The  whole  weight  of  the  surgeon's  trunk 
can  be  thrown  upon  the  end  of  the  lever  furnished  by  the  patient's  leg, 
the  hands  of  the  surgeon,  pulling  upon  the  popliteal  space,  furnishing 
resistance.     After  the  limb  has  yielded  and  the  adhesions  are  broken, 

it  can  be  straightened  if  the  pa- 
tient is  turned  upon  the  face;  a 
downward  force  being  applied  to 
the  heel,  resistance  being  fur- 
nished by  a  cushion  placed  under 
the  patient's  knee.  When  sub- 
luxation of  the  tibia  is  present 
it  must  be  corrected.  This  can- 
not be  done  so  well  by  this 
method  as  by  the  instrumental 
method  to  be  described.     After 


Fig.   160. — Jointed    Traction  Knee    Splint 
Applied. 


Fig.     i6r.- 


-Goldthwait's     Genuclast 
Applied. 


correction,  the  limb  should  be  well  surrounded  with  sheet  wadding  and 
a  stiff  bandage  applied,  the  limb  being  held  straight  until  the  plaster 
has  become  hard.  The  procedure  is  sometimes  followed  by  pain,  and 
opiates  may  be  necessary  for  a  few  days.  Such  measures  are  not 
required  except  in  resistant  cases.     The  dangers  incurred  by  this  pro- 


TUBERCULOUS  DISEASE   OF    THE  KNEE.  165 

cedure  are  not  so  great  as  would  be  supposed.  The  danger  of  rupture 
of  the  artery  can  be  avoided  by  care.  Separation  of  the  epiphysis  of 
the  femur  ma)-  take  place,  but  is  cured  by  the  fi.xation  requisite  to  treat- 
ment, and  should  not  occur  if  the  force  is  carefully  applied.  P>acture 
of  the  femur  and  tibia  can  be  avoided  by  care. 

If  the  deformity,  flexion,  remains  uncorrected  in  severe  ostitis  of  the 
knee-joint,  a  subluxation  of  the  tibia  backward  takes  place,  due  to 
the  contraction  of  the  hamstring  muscles.  This  is  due  in  part  to  the 
spasm  of  the  hamstring  muscles,  which  have  pulled  the  tibia  backward, 
but  chiefly  to  the  fact  that  owing  to  adhesions  the  flexed  tibia  is  unable 
to  slide  forward  over  the  condyles  of  the  femur,  as  happens  in  normal 
extension.  Attempts  to  straighten  the  leg  simply  crowd  the  anterior 
edge  of  the  tibia  into  the  condyles.  To  obviate  this  the  head  of  the 
tibia  should  be  pressed  forward  and  upward  to  the  same  degree  that  the 
leg  is  raised. 

The  most  efihcient  method  of  accomplishing  this  is  by  the  use  of  the 
apparatus  shown  in  the  figure  called  by  Goldthwait,'  who  modified  it 
from  the  original  apparatus,  the  "genuclast." 

Pressure  forward  on  the  head  of  the  tibia  is  exerted  by  turning  the 
handle;  this,  by  means  of  a  screw  force,  pushes  a  plate  forward  against 
the  tibia,  working  through  a  band.  The  calf  muscles  protect  the  artery 
and  nerve  from  injurious  pressure.  Counter-pressure  is  secured  by 
means  of  leather  straps,  which  are  passed  respectively  over  the  knee 
and  leg,  protected  by  a  thick  layer  of  saddler's  felt.  Several  straps 
will  be  needed  at  the  knee  to  prevent  loss  of  counter-pressure,  as  the 
limb  is  made  straighter.  Another  strap,  under  the  leg,  secures  the 
lower  part  of  the  leg.  The  side  bars,  bands,  and  plate  of  the  apparatus 
should  be  of  strong  steel. 

The  apparatus  is  put  on  the  limb  in  a  flexed  position  (after  ruptur- 
ing adhesions  by  forcible  flexion  if  that  is  needed),  the  head  of  the  tibia 
is  pushed  forward  as  far  as  is  advisable,  and,  by  means  of  the  end  of 
the  appliance,  which  serves  as  a  handle,  the  leg  is  extended ;  the  press- 
ure forward  of  the  head  of  the  tibia  can  be  increased,  and  the  counter- 
pressure  regulated  if  necessary,  by  loosening  such  of  the  straps  as 
extension  of  the  limb  may  tighten  too  much.  In  some  cases  the  reduc- 
tion may  be  accomplished  at  one  time,  while  in  others  successive  appli- 
cations of  the  apparatus  are  necessary.  Adhesions  of  the  patella  to 
the  front  of  the  femur  may  constitute  an  obstacle  to  reduction  without 
cutting.  The  treatment  of  cases  resisting  this  method  will  be  consid- 
ered in  the  section  of  this  chapter  on  operative  treatment. 

Experiments  on  the  cadaver  which  were  conducted  by  one  of  the 
writers  at  the  Harvard  Medical  School,  through  the  courtesy  of  Drs. 
C.  B.  Porter  and  T.  Dwight,  showed  that  by  means  of  this  appliance 
'  Boston  Med.  and  Surg.  Jour.,  September  7th,  1S93. 


1 66  ORTHOPEDIC  SURGERY. 

the  tibia  could  readily  be  pushed  forward  to  any  desired  extent.  On 
normal  joints,  the  tibia  can  be  pushed  forward  to  a  considerable  dis- 
tance without  rupturing  the  ligaments. 

In  general,  correction  of  flexion  deformity  under  ether  is  the  best 
method  except  in  slight  cases. 

Abscess. — The  treatment  of  abscess  is  the  same  that  is  recom- 
mended for  the  treatment  of  abscesses  at  the  hip,  except  that  they  are 
generally  more  superficial  and  can  be  opened  earlier.  They  do  not 
dissect  about  between  the  muscles  to  the  extent  that  hip  abscesses 
often  do. 

Operative  Treatment  of  Tumor  Albus. 

The  operative  measures  to  be  considered  are : 

1.  Excision. 

2.  Arthrectomy  and  erasion. 

3.  Amputation  of  the  leg. 

I.  Excision  of  the  knee-joint  is  to  be  undertaken  in  those  cases  in 
which  conservative  treatment  has  failed  to  arrest  the  progress  of  the 
disease ;  in  which  originally  the  disease  is  too  extensive  to  warrant  con- 
servative treatment ;  in  which  the  general  health  is  failing  and  the  dis- 
ease failing  to  improve  under  efficient  conservative  measures.  In 
adults  it  is  to  be  undertaken  earlier  than  in  children,  as  the  progress  of 
the  disease  is  in  the  former  less  favorable  than  in  the  latter. 

Excision  is  inferior  to  conservatism  as  a  treatment  of  knee-joint 
disease  in  children,  because  the  functional  results  are  not  so  good. 

Excision  of  the  knee  is  also  performed  to  correct  the  deformity 
caused  by  bony  ankylosis  at  an  angle  of  flexion. 

It  would  be  fair  to  assert  that  in  patients  between  fiv-e  and  twenty, 
the  mortality  from  the  operation,  near  and  remote,  would  not  be  far 
from  ten  per  cent,  being  less  rather  than  more  than  this  percentage. 

The  functional  results  after  excision  are,  however,  inferior  to  the 
results  after  conservative  treatment.  Ankylosis  is  to  be  hoped  for  after 
excision  and  is  complicated  by  a  tendency  to  flexion  of  the  apparently 
ankylosed  joint. 

It  may  be  said  with  regard  to  the  amount  of  shortening  after  excis- 
ion in  cases  in  which  the  epiphyseal  lines  are  saved  that  it  is  likely  to 
be  only  moderate,  although  even  then  it  is  more  than  after  conservative 
treatment." 

Operation. — -The  operation  of  excision  of  the  knee-joint  is  per- 
formed as  follows : 

The  leg  should  be  carefully  prepared  for  an  aseptic  operation.  The 
use  of  the  Esmarch  bandage  and  tourniquet  is  advisable.  The  joint  is 
opened  by  a  free  anterior  incision  passing  from  the  inner  to  the  outer 
'Arch.  f.  klin.  Chir.,  1S85,  iv..  32. 


TUBERCULOUS  DISEASE   OF   THE  KNEE. 


167 


side  of  the  joint  slightly  below  the  patella,  the  ligamentum  patellae  is 
divided,  the  periosteum  and  muscular  attachments  are  cleared  from  the 
ends  of  the  bones,  the  ligaments  are  cut,  and  the  articular  end  of  the 
femur  protruded  through  the  incision  and  as  much  as  seems  desirable 
sawed  off.  In  the  same  way  the  tibia  is  cleared  and  protruded  as  a 
safeguard  against  injuring  the  popliteal  vessels.  The  patella  should  be 
removed  if  it  is  diseased. 

In  children  it  is  desirable  to  avoid  removing  bone  below  the  line  of 
the  epiphysis — a  precaution  not  necessary  in  adults.  It  is  best  at  first 
to  remove  a  very  thin  section,  just  enough 
to  take  all  the  articular  surface  of  both 
bones,  and  then  to  remove  another  section 
if  the  disease  is  very  extensive,  or  if  only 
foci  of  disease  are  seen  to  scoop  them  out 
extensively  with  a  sharp  spoon. 

It  is  of  the  utmost  importance  to  at- 
tend carefully  to  the  plane  of  section  which 
the  saw  makes  in  removing  the  articular 
surfaces.  If  these  planes  are  ever  so 
slightly  oblique,  the  whole  axis  of  the  limb 
is  distorted  and  the  line  of  weight-bearing 
is  wrong  and  tends  to  cause  angular  de- 
formity at  the  knee.  In  the  femur  the 
plane  of  section  should  be  parallel  to  the 
articular  surface  and  not  perpendicular  to 
the  shaft  of  the  bone,  which  would  make 
it  oblique  at  the  joint.  As  soon  as  sec- 
tion of  the  bones  has  been  made,  the 
new  surfaces  should  be  placed  in  con- 
tact and  the  line  of  the  limb  carefully  ob- 
served. 

To  secure  fixation  the  bones  may 
be  wired  together  or  fastened  to  each 
other  by  wire  nails  or  pegs  of  ivory  or  bone.  A  wire  posterior  splint 
may  be  used,  but,  in  general,  a  plaster-of-Paris  bandage  reinforced 
by  a  steel  bar  and  with  a  window  cut  for  dressing,  the  bandage  includ- 
ing the  foot,  furnishes  the  best  means  of  fixation,  the  bones  having  been 
fixed  accurately  in  position  by  some  of  the  means  mentioned  and  the 
limb  after  that  handled  very  carefully.  The  only  objection  to  it  is  that 
in  the  profuse  discharge  of  serum  which  takes  place  necessarily  from 
so  large  a  wound  within  the  first  twenty-four  hours,  the  plaster  is  likely 
to  be  stained  through  and  may  have  to  be  changed.  But  if  a  suffi- 
ciently heavy  dressing  is  put  on,  this  will  ordinarily  not  happen  to  any 
extent,  or  if  it  does  a  light  dressing  can  be  applied  outside  to  protect 


Fig.  162.— Osteotomy  for  Deform- 
ity with  Ankylosis.  (After 
Hoffa.) 


1 68  ORTHOPEDIC  SURGERY. 

the  stained  spot.  Occasionally  the  plan  is  useful  to  dress  the  limb 
after  operation  in  a  heavy  dressing  and  on  the  next  day  to  redress  it 
and  apply  the  plaster.  In  this  way  one  may  be  almost  sure  of  a  dress- 
ing which  can  be  left  on  almost  indefinitely,  provided  the  operation  has 
been  aseptic. 

There  are  two  precautions  to  be  observed  in  putting  the  leg  up  in 
splints  or  in  plaster:  first,  the  tendency  to  eversion ;  and  second,  the 
tendency  to  dropping  backward  of  the  head  of  the  tibia.  With  moder- 
ate precautions  these  deformities  may  be  avoided.  When  the  bones 
are  wired  together,  if  the  holes  which  are  bored  in  the  tibia  for  the 
insertion  of  the  wire  are  placed  well  backward  and  the  corresponding 
holes  in  the  femur  well  forward,  much  will  be  done  to  counteract  this 
backward  displacement  of  the  leg  upon  the  thigh. 

A  protection  splint  is  to  be  worn  for  some  time  to  prevent  the  recur- 
rence of  flexion.  It  is  much  the  wiser  course  to  have  the  patient  wear 
a  perineal  crutch  (in  the  form  of  a  Thomas  knee-splint),  which  shall 
prevent  bearing  any  weight  on  the  leg  until  several  months  after  oper- 
ation. If  this  precaution  is  neglected,  permanent  flexion  of  the  limb  is 
likely  to  occur  or  a  lighting  up  of  the  original  disease. 

Excision  of  the  Knee  for  Angular  Ankylosis. — When  excision  of 
the  knee  is  done  for  angular  ankylosis,  the  only  modification  of  the 
operation  which  is  necessary  is  the  removal  of  a  wedge  of  bone  large 
enough  to  allow  the  ends  of  the  bone  to  come  together,  so  that  the 
angularity  is  obliterated. 

Osteotomy  of  the  femur  is  a  measure  which  may  be  used  to  correct 
flexion  deformity  at  the  knee  too  strong  to  be  overcome  by  forcible 
straightening.  The  osteotomy  should  be  linear  and  as  near  the  joint 
epiphyseal  line  as  possible.  This  can  be  employed  in  place  of  a  wedge- 
shaped  excision  for  angular  deformity,  as  not  involving  shortening. 
The  osteotomy  is  followed  by  careful  straightening  of  the  limb.  The 
advantage  of  this  method  lies  in  the  fact  that  any  motion  remaining 
at  the  joint  is  not  destroyed  as  it  must  be  in  excision.  Its  disadvan- 
tage is  that  the  condyles  of  the  femur  are  necessarily  displaced  for- 
ward to  form  an  angle  with  the  shaft.  i\  linear  or  wedge-shaped  oste- 
otomy of  the  upper  part  of  the  tibia  has  been  described  by  Konig  for 
•  the  same  purpose. 

2.  Arthrectomy. — As  a  substitute  for  excision,  what  has  been 
termed  arthrectomy  or  erasion  has  been  employed. 

Arthrectomy  consists  of  the  removal  of  all  palpable  and  obvious 
portions  of  diseased  tissue,  whether  in  the  synovial  membrane  or  else- 
where, leaving  what  appears  to  be  healthy  tissue.  Two  advantages  are 
claimed  for  this  operation  over  excision:  (i)  That  it  does  not  interfere 
with  the  growth  of  the  limb,  and  (2)  that  mobility  of  the  joint  may  be 
preserved.     It  may  be  added  that  the  latter  is  an  exceptional  event  and 


TUBERCULOUS  DISEASE  OE   THE  KNEE.  169 

not  altogether  so  desirable  or  safe  an  ending  under  the  circumstances 
as  bony  ankylosis.  The  objection  to  the  operation  is  that  it  is  not 
thorough,  and  oftener  than  excision  fails  to  eradicate  the  disease. 

The  operation  offers  advantage  over  excision  only  in  the  case  of  chil- 
dren and  chiefly  before  the  disease  has  made  extensive  progress.  It  is 
easy  to  see  that,  if  any  extensive  disease  of  the  bone  is  present,  any 
measure  short  of  thorough  removal  must  necessarily  fail.  The  opera- 
tion is,  therefore,  not  suited  to  cases  in  which  there  are  many  sinuses 
and  bone  enlargement,  but  to  milder  cases  as  a  less  severe  operation 
than  formal  excision. 

In  the  matter  of  risk  there  is  little  to  choose  between  this  operation 
and  excision,  for  the  immediate  death  rate  under  proper  precautions 
is  very  small  in  both  operations.  The  risk  of  operative  tuberculous  in- 
fection, alluded  to  so  often  in  speaking  of  operations  upon  tuberculous 
joints,  is  present  in  arthrectomy  as  in  excisions. 

Operation. — The  operation  itself  may  be  described  as  follows :  The 
joint  is  opened  as  in  cases  of  excision  and  the  tuberculous  synovial  mem- 
brane as  far  as  possible  should  be  dissected  out ;  if  diseased  spots  are 
found  in  the  bone  or  have  been  previously  located  by  the  ,f -ray,  these  foci 
should  be  removed  by  the  curette  or  chisel,  and  the  cavity  left  in  the  bone 
wiped  out  v^ith  pure  carbolic  acid  and  alcohol,  and  the  joint  sewed  up 
or  drained  according  to  the  extent  of  the  disease  and  the  general  aspect 
of  the  case.  If  the  whole  epiphysis  is  diseased,  excision  is  of  course 
unavoidable.  Instances  of  excellent  recovery  with  complete  healing 
occur  after  this  operation,  and  success  has  followed  the  procedure  in 
many  cases  in  the  practice  of  the  writers.  The  most  thorough  removal 
possible  of  all  tuberculous  tissue  in  the  affected  joint  is  essential,  neces- 
sitating sometimes  complete  dissection  and  removal  of  all  of  the  syno- 
vial membrane,  as  well  as  careful  curetting  of  the  bone.  The  patella 
should  be  removed  or  left,  according  to  its  condition. 

The  parts  of  the  knee-joint  to  be  most  carefully  investigated  for 
diseased  foci  are  the  synovial  pockets  and  the  epiphyseal  lines  of  the 
femur  and  tibia  at  their  lateral  aspects.  Here  one  may  find  foci  of  tu- 
berculous material  extending  into  the  epiphysis,  without,  however,  in 
most  cases  crossing  the  epiphyseal  lines. 

The  after-treatment  should  be  like  that  of  excision,  except  that  wir- 
ing or  nailing  the  bones  together  is  not  necessary,  as  the  ligaments 
should  be  preserved  so  far  as  possible. 

Flexion  of  the  limb  may  follow  arthrectomy  as  well  as  excision  '  in 
cases  in  which  protection  to  the  joint  has  been  discontinued  too  early, 
so  that  the  after-treatment  should  be  as  careful  and  as  prolonged  as 
after  excision  of  the  joint. 

3.  Amputation. — In  cases  of  extreme  disease  of  the  knee-joint 
'  Hofmeister :  Abst.  in  Arch.  f.  Orth  ,  i.,  2. 


I/O  ORTHOPEDIC  SURGERY. 

amputation  of  the  thigh  is  necessary  as  a  hfe-saving  measure.  As  for 
the  indications  determining  a  choice  between  excision  and  amputation, 
it  can  be  said  that  when  the  patient's  reparative  power  is  slight  an  am- 
putation is  to  be  preferred.  The  question  is  largely  one  of  individual 
judgment ;  if  excision  is  first  tried  and  fails  to  arrest  the  disease,  and 
finally  amputation  has  to  be  performed,  the  patient's  chances  are,  of 
course,  injured  by  the  choice  of  excision  in  the  first  place.  In  the  adult 
extensive  removal  of  the  bones  may  be  accomplished  by  excision  with- 
out any  danger  of  arrest  of  growth,  and  few  patients  can  be  brought  to 
consent  to  amputation  of  a  limb  so  long  as  any  other  method  of  treat- 
ment holds  out  the  faintest  prospect  of  relief.  In  children  amputation 
should  be  deferred  to  the  last  moment  and  excision  given  the  prefer- 
ence, unless  the  eradication  of  the  disease  would  necessitate  the  re- 
moval of  so  much  bone  that  a  useless  leg  would  result  from  that. 

In  children,  therefore,  the  operation  could  be  advised  only  when  the 
joint  was  hopelessly  disorganized  and  so  much  of  the  shaft  of  the  long 
bones  was  evidently  diseased  that  an  excision  was  not  practicable. 

Summary. 

The  treatment  of  tumor  albus  should  consist  m.  fixation  of  the  dis- 
eased joint  by  plaster  of  Paris  or  some  suitable  splint,  with  traction  in 
cases  in  which  the  muscular  spasm  is  very  marked.  If  ambulatory 
treatment  is  to  be  undertaken  (which  is  almost  invariably  to  be  advised), 
protection  is  also  necessary.  This  is  furnished  by  the  Thomas  splint, 
a  high  shoe,  and  crutches,  or  by  the  use  of  a  protection  splint  similar 
to  the  one  used  in  hip  disease,  etc.  fixation  can  be  discontinued  at 
the  close  of  the  acute  stage,  but  protection  is  advisable  for  a  much 
longer  time. 

Excision  is  not  in  children  an  advisable  method  of  treatment  until 
mechanical  measures  have  proved  inefficient  after  a  faithful  trial,  and 
the  same  is  true  of  arthrectomy.  The  latter  is  not  suitable  for  adults. 
Deformities  should  be  corrected  as  they  arise. 


CHAPTER    V. 

TUBERCULOUS     DISEASE     OF     THE     ANKLE     AND 
OTHER    JOINTS. 

ANKLE. 

Ankle  (Symptoms. — Diagnosis. — Prognosis.  — Treatment).  —  Shoulder  (Symp- 
toms.— Treatment). — Elbow  (Symptoms. — Treatment). — Wrist  (Symptoms. — 
Treatment).  —  Sacro-iliac  disease  (Etiology.  —  Symptoms.  —  Diagnosis.  — 
Prognosis. — Treatment). 

The  seat  of  the  disease  may  be  in  the  articular  end  of  the  tibia  or 
in  the  astragulus;  and  other  adjacent  bones  may  be  involved  secondarily 
or  independently,  as  the  os  calcis,  the  scaphoid,  cuboid,  and  cuneiform 
bones.  The  pathological  process  does  not  differ  from  that  already 
described,  but  on  account  of  the  numerous  synovial  sacs  in  the  tarsus 
and  the  proximity  of  the  bones  to  each  other,  extension  of  the  disease 
is  favored. 

Symptoms. — Pain  and  tenderness  of  the  whole  joint  to  pressure  and 
motion  may  or  may  not  be  present.  Tenderness,  as  a  rule,  is  present 
over  the  joint  capsule  in  front,  and  perhaps  under  the  malleoli,  and 
swelling  and  heat  are  invariable  accompaniments  of  the  affection.  Mus- 
cular rigidity  is  marked  in  most  cases. 

Lameness  is  an  early  and  a  marked  symptom.  Sometimes  it  is  pro- 
duced by  the  pain  which  weight-bearing  causes  in  walking,  but  more 
often  by  the  muscular  stiffness  which  will  not  allow  the  ankle-joint  to 
bend.  The  swelling  consists  of  a  boggy  infiltration  of  the  soft  parts 
around  the  ankle,  along  wath  a  distention  of  the  joint  capsule  by  gelati- 
nous granulations.  Li  character  it  is  oedematous.  This  swelhng  is 
uniform  around  the  ankle,  except  when  an  abscess  is  pointing  on  one 
side.  The  depressions  in  the  contour  of  the  ankle  in  front  and  behind 
the  malleoli  disappear  in  the  swelling.  The  foot  in  affections  of  the 
ankle-joint  usually  assumes  a  position  with  the  toes  pointing  downward, 
and  in  chronic  cases  with  the  foot  slightly  rolled  outward  (in  the  posi- 
tion of  equino-valgus).  This,  however,  is  not  the  only  malposition,  for 
the  foot  may  assume  the  position  of  pure  talipes  calcaneus.  These 
malpositions  are  brought  about  by  the  abnormal  tonic  muscular  contrac- 
tion, and  these  deformities  yield  of  themselves  and  the  foot  returns  to 
its  normal  position  when  the  irritation  is  quieted  in  the  joint  by  proper 
treatment. 

171 


172 


ORTHOPEDIC  SURGERY. 


Wasting  of  the  thigh  and  calf  muscles  occurs.    Abscesses  may  occur. 

When  the  disease  attacks  the  medio-tarsal  or  tarso-metatarsal  joints, 

the  anterior  part  of  the  instep  appears  swollen  and  is   hot  and  tender. 


Fig.  163. — Tuberculous  Ankle-joint.  Diffuse  tuberculosis  of  tarsus.  Primary  focus  lost  in 
the  area  of  destruction,  a,  Tuberculous  infiltration  of  soft  parts  ;  b,  tuberculous  soften- 
ing of  tarsal  bones.     (Nichols.) 

Motion  at  the  ankle  is  but  little  restricted,  but  motion  in  the  anterior 
part  of  the  foot  is  attended  by  pain  and  is  usually  lost.  The  location 
of  the  affection  is  evident  from  examination.     If  the  os  calcis  is  attacked 


Fig.    164.— Tuberculous   Ankle,     tf,  Lower  end  of   tibia;   b,  tuberculous   cavity  in  tibia;    t, 
tuberculous  disease  of  calcis  :  </,  tuberculous  disease  of  astragalus.     (Xichols..) 

primaril}'  it  is  manifested  by  the  same  symptoms  of  local  inflammation 
without  any  symptoms  referable  to  the  ankle-joint. 

The  recognition  of  disease  of  the  ankle  is  dependent  on  the  symp- 
toms given  above. 


TUBERCULOUS  DISEASE   OE    THE  ANKLE. 


1/3 


Diagnosis. — The  most  troublesome  affections  to  diagnosticate  from 
ankle-joint  disease  are  \h&  functional  affections  which  result  often  from 
sprains  and  injuries.  Here  it  is  not  uncommon  to  find,  in  hypersensi- 
tive women  chiefly,  a  limitation  of  motion  of  the  ankle,  with  much  pain 
on  manipulation  and  pressure ;  there  may  be  swelling  left  over  frf)m  the 
injury,  and  the  question  to  be  decided  is  whether  any  disease  of  the 
joint  exists  which  can  well  be  made  worse  if  the  patient  goes  about,  or 
if  it  is  a  disturbance  of  circulation  and  innervation  which  can  be  over- 
come by  judicious  management.  In  one  case  rest  is  indicated,  in  the 
other  activity.  The  diagnosis  of  functional  joint  disease  is  considered 
in  full  in  the  proper  place. 

One  must  depend  chiefly  upon  the  existence  of  the  objective  signs 
of  ankle  disease,  rather  than  upon  the  patient's  feelings;  allowing, 
however,  due  weight  to  the  history 
of  the  affection  and  the  patient's 
sex  and  constitution. 

Inflammatory  flat-foot  may  at 
times  present  symptoms  similar  to 
those  of  ankle-joint  disease.  Rest 
and  measures  to  quiet  the  process 
will  quickly  control  the  symptoms 
in  flat-foot  but  not  in  tuberculosis. 

The  ,i"-ray  is  of  value  in  estab- 
lishing the  diagnosis. 

Prognosis. — Unless  the  disease 
is  advanced,  children  who  are  in 
good  condition  as  a  rule  make  good 
progress  under  conservative  treat- 
ment. The  prognosis  is  somewhat 
better  when  parts  other  than  the 
astragalo-tibial  joint  are  affected. 
The  prognosis  in  adults  under  con- 
servative treatment  is  less  favorable. 

Mechanical  Treatment. ^Protection  from  jar  is  indicated,  as  well  as 
fixation  of  the  joint — as  will  be  readily  seen  if  it  be  borne  in  mind  that 
in  locomotion  the  whole  weight  of  the  body  is  borne  at  each  step  upon 
the  comparatively  small  surface  of  the  upper  articulating  portion  of  the 
astragalus.  Fixation  of  the  ankle  in  a  stiff  bandage,  while  allowing  the 
patient  to  walk  upon  the  limb,  is  a  manifest  error,  as  affording  little  or 
no  real  protection  to  the  joint.  Fixation  is  of  advantage  in  the  more 
acute  stages  of  the  affection,  and  is  readily  furnished  by  means  of  stiff 
bandages.  A  plaster-of-Paris  bandage  is  the  most  convenient  appliance, 
and  should  be  carried  above  the  knee  so  as  to  fix  that  joint  also.  A 
fixation  ankle  brace  (Chapter  XXL,  17)  may  be  used  instead  of  the 


Fig.  165.— Ankle-joint  Disease  at  an  Early 
Sta.are. 


174 


ORTHOPEDIC  SURGERY. 


plaster-of-Paris  bandage.  Protection  can  be  furnished  either  by  means 
of  crutches  or,  more  thoroughly,  by  means  of  protective  sphnts  with 
perineal  supports  described  for  the  knee-joint.  The  Thomas  knee-splint 
is  one  form  available  (Chapter  XXI.,  14). 

Such  apparatus  for  fixation  and  protection  should  be  worn  through 
the  acute  stage  of  the  disease.  If  abscesses  form  they  should  be  in- 
cised and  traced  to  their  source,  and  if  loose  bone  is  detected  this 
should  be  removed.  If  the  foot  assumes  a  malposition,  this  should  be 
corrected ;  this  is  best  done  by  applying  a  plaster  bandage  to  the  foot 
in  its  malposition  and  quieting  thereby  the  inflammation  so  much  that 


Fig.  i66.— Tuberculous  Ankle.     Advanced  Stage. 


in  two  weeks  the  malposition  will  be  found  less  and  an  improved  posi- 
tion can  be  gained.  Bier's  congestive  treatment  is  applicable  in  cases 
of  tuberculosis  of  the  ankle.  The  general  health  should  be  carefully 
inquired  into  and  appropriately  treated.  All  these  procedures  may  be 
grouped  together  and  be  said  to  complete  the  expectant  method  of 
.treatment.' 

The  conservative  plan  fully  carried  out  is  justifiable  in  a  large  pro- 
portion of  cases,  and  on  the  whole  the  results  obtained  are  good.  In 
cases  of  tuberculous  disease  of  the  ankle  where  the  progress  is  not  sat- 
isfactory, the  decision  of  continuance  of  conservative  treatment  or  the 
adoption  of  operative  interference  is  one  which  is  based  largely  upon 
the  patient's  age  and  the  circumstances  of  attendant  care. 

'  N.  Y.  ]\Ied.  Rec.  August  21st,  iSSo.  p.  197  :  Am.  Jour,  of  Obstet.,  iSSo,  p. 
434- 


TUBERCULOUS  DISEASE   OF   THE  ANKLE. 


/  0 


Operative  Treatment. — There  are  three  alternatives  left  if  the  ex- 
pectant method  fails.  The  mildest  form  of  operative  interference  con- 
sists in  curetting  the  sinuses  and  removing  what  diseased  bone  it  is 
possible  to  reach.  Occasionally  it  may  be  possible  to  scrape  out  a  focus, 
of  tuberculous  material  in  the  os  calcis,  but  in  the  tarsus  proper  it  is 
rarely  a  satisfactory  procedure.  The  second  operation  is  a  formal  ex- 
cision of  the  diseased  bones.  The  third  and 
most  radical  measure  is  amputation  of  the 
leg  or  foot. 

The  question  arises,  Will  the  disease  in 
the  foot  cease  if  the  bone  is  removed  1  It 
may  be  said  that,  if  thoroughly  removed  in 
children,  relapse  is  unlikely  to  occur.  More 
relapses  occur  from  partial  operations  and 
from  gougings  and  scrapings  than  from  any 
other  cause.  The  earlier  excision  is  done  and 
the  more  thoroughly  the  diseased  bone  is 
removed  from  the  tarsus,  the  better  is  the 
result. 

The  operation  should  be  performed  by 
the  subperiosteal  method ;  the  diseased  tissue 
should  be  removed  from  the  end  of  the  tibia 
and  the  astragalus  removed  entire  with  the 
top  of  the  OS  calcis,  if  diseased. 

There  are  many  modifications  of  the  lat- 
eral incisions  which  are  in  common  use  and 
other  incisions  radically  differing;  but  of  all 
methods  preference  must  be  given,  in  the 
opinion  of  the  writers,  to  that  of  Kocher, 
which  has  proved  eminently  satisfactory  in 
their  experience  when  a  formal  excision  is  to 
be  done. 

The  method  is  as  follows:  The  foot  is 
held  at  a  right  angle  and  a  superficial  incision 
is  made  along  the  outer  border  just  below  the 
external  malleolus,  reaching  from  the  tendo  Achillis  to  the  extensor  ten- 
dons. The  peroneal  tendons  are  dissected  out,  secured  by  sutures, 
and  then  cut  by  a  second  and  deeper  incision.  The  capsule  along  the 
anterior  and  posterior  surfaces  of  the  tibia  is  cut,  the  external  lat- 
eral ligament  divided,  and  the  ankle-joint  thus  opened  freely  from 
the  side.  The  foot  is  then  dislocated  inward  as  far  as  is  desired,  and 
the  joint  can  be  inspected  to  any  extent.  After  the  diseased  parts 
have  been  removed,  the  foot  is  reduced  to  its  proper  position,  the 
peroneal    tendons   are    united,   and   the  wound  is  closed.     Wlien  the 


Fig.  167.— Treatment  of  Ankle- 
joint  Disease  by  Thomas. 
Knee  splint  and  plaster-of- 
Paris  bandage  on  ankle. 


176 


ORTHOPEDIC  SURGERY. 


foot  is  dislocated,  an  admirable  view  is  obtained  of  the  interior  of 
the  joint. 

The  after-treatment  of  cases  of  ankle-joint  excision  is  similar  to  the 
treatment  of  the  others  spoken  of.  Asepsis  and  immobilization  in  a 
correct  position  are  the  requirements ;  and  to  this  end  infrequent  dress- 
ings are  very  desirable.  Plaster  of  Paris  applied  outside  of  a  heavy 
dressing  is  very  serviceable,  as  in  knee-joint  excision.  An  accurate  and 
equally  efficient  splint  is  a  wire  posterior  splint,  which  is  made  of  a  rod 
of  "  copper-washed  iron  wire  "  three-sixteenths  of  an  inch  in  diameter, 
which  is  bent  to  fit  the  leg  and  padded  except  at  the  ankle,  where  it  is 
covered  with  rubber  tubing  and  can  be  rendered  aseptic  and  incorpo- 
rated in  the  dressing  there.     The  rest  of  the  splint  is  padded.     What- 


FlG.  16S. — Radiograph  of  Ankle  Ten  Ye?rs  after  Cure  following  Removal  of  Astragalus  for 
Disease.     (Case  of  Dr.  A.  T.  Cabot.) 

ever  splint  is  used,  one  must  be  careful  to  see  that  the  foot  is  at  a  right 
angle  to  the  leg  and  in  the  same  plane.  For  a  long  time  after  excision 
the  joint  should  be  protected  from  weight-bearing  by  the  application  of 
a  Thomas  splint  or  some  such  appliance. 


SHOULDER. 

Symptoms. — The  general  symptoms  of  ostitis  of  the  shoulder  differ 
in  no  way  from  those  in  the  usual  form  of  this  disease  in  other  more 
commonly  affected  joints,  except  that  stiffness  of  the  joint  and  malposi- 
tions due  to  muscular  spasm  are  less  noticeable  on  account  of  mobility 
of  the  scapula.  The  disease  is  insidious,  extremely  chronic,  prone  to 
suppuration,  and  decided  impairment  of  the  joint  is  likely  to  result. 

Pain  is  of  a  dull  aching  character,  which  is  usually  aggra\-ated  at 


TUBERCULOUS  DISEASE   OF   THE  SHOULDER.      177 

night,  and  is  referred  either  to  the  joint  itself  or  to  the  middle  of  the 
arm  near  the  insertion  of  the  deltoid.  In  many  cases  this  symptom  is 
absent  or  very  slight.  A  slight  increase  of  surface  temperature  may 
be  detected.  There  will  usually  be  found  a  tenderness,  frequently 
localized  over  a  small  area,  generally  over  the  anterior  surface  of  the 
joint,  but  sometimes  on  its  posterior  aspect.  The  patient  instinctively 
holds  the  arm  at  rest,  and  attempts  at  passive  motion  provoke  muscu- 
lar spasm,  and  if  the  attempt  is  persisted  in,  the  humerus  and  scapula 
are  seen  to  move  together.     Early  in  the  disease  a  change  in  contour  of 


Fig.  169.— Disease  of  Right  Shoulder-joint  Showing  Atrophy  and  Change  in  Outline. 

the  joint  becomes  apparent,  which  is  due  to  enlargement  of  the  head  of 
the  humerus  as  well  as  to  muscular  atrophy.  When  the  swelling  is  due 
to  effusion  within  the  joint,  the  shoulder  appears  fuller  and  broader 
than  normal,  and  this  is  seen  best  in  looking  down  on  the  patient ;  the 
natural  depressions  in  front  of  and  behind  the  joint  become  either  oblit- 
erated or  are  the  sites  of  prominences. 

Suppuration  may  occur.  The  subsequent  course  is  slow,  the  result 
depending  on  the  extent  of  the  degenerative  process,  which  may  termi- 
nate soon  after  evacuation  of  the  pus  or  continue  to  complete  destruc- 
tion of  the  head  of  the  humerus. 

The  possible  results  are:  recovery  v.'ith  a  stiff  joint  (ankylosis), 
deformity  and  impaired  muscular  power,  or  entire  destruction  of  the 
12 


178 


ORTHOPEDIC  SURGERY. 


head  of  the  bone ;  and  in  children  later  arrest  of  development  of  the 
humerus  may  result. 

Treatment. — In  tuberculous  ostitis  at  the  shoulder-joint  the  indica- 
tions for  treatment  are  practically  the  same  as  those  presented  in 
other  joints.  Distraction  is  not  indicated  in  disease  of  the  shoul- 
der, as,  owing  to  the  laxity  of  the  joint,  the  weight  of  the  dependent 
arm,  if  kept  at  rest,  is  sufficient  to  separate  the  humerus  from  the 
opposing  bone  surface  of  the  scapular  articulation.  In  very  painful 
cases,  should  traction  be  recjuired,  it  may  be  applied  by  weight  and  pul- 
ley traction  during  recumbency. 

On  the  whole,  the  results  of  the  conservative  treatment  of  tubercu- 
lous shoulder-joint  disease  are  satisfactory  except  in  the  case  of  persons 


Fig.  170. — Same  Case  as  Fig.  \t 


Showing  limitation  of  abduction  in  attempt  to  raise  both 
elbows. 


whose  general  condition  is  decidedly  bad.  The  great  freedom  of  move- 
ment of  the  scapula  allows  many  arm  motions  to  take  place  without  any 
movement  of  the  head  of  the  humerus  in  the  glenoid  cavity,  so  that  it 
is  easy  to  secure  almost  complete  rest  to  the  affected  joint. 

Excision  of  the  joint  should  be  performed  if  conservati\-e  treatment 
fails,  being  done  earlier  in  adults  than  in  children. 

The  longitudinal  anterior  incision  is  in  general  the  most  useful  for 
excision  of  the  shoulder.  The  periosteum  is  divided  with  a  bone  knife, 
inserted  along  the  inner  border  of  the  bicipital  groove.  The  arm  is 
rotated  both  outward  and  inward,  and  the  periosteum  and  muscular 
attachments  are  removed  as  they  appear.  The  head  can  be  removed 
with  the  keyhole  or  the  chain  saw,  removing  as  much  of  the  bone  as  is 


TUBERCULOUS  DISEASE   OF   THE  ELBOW. 


179 


diseased.  The  operation  is  performed  subperiosteally  and  the  head  of 
the  bone  may  be  thrown  out  of  the  wound  and  thus  sawed  off.  In  after- 
treatment  very  good  fixation  can  be  obtained  by  bandaging  the  arm  to 
the  side,  with  a  thick  pad  between  the  body  and  the  inner  side  of  the 
arm.     Plaster-of-Paris  dressing  around  the  arm  and  chest  affords  the 


Fig.  171. — Radiograph  of  Tuberculous  Disease  of  Left  Shoulder.     (Dr.  C:  F.  Painter.) 

best  fixation;  and  after  the  need  of  complete  fixation  is  passed,  a  sling 
answers  every  purpose. 


ELBOW. 


Symptoms. — The  disease  may  begin  with  pain,  but  this  is  not  severe 
and  often  is  entirely  absent.  Limitation  of  extension  of  the  forearm  is 
a  constant  and  early  symptom,  motion  in  this  direction  being  distinctly 
restricted  when  flexion,  pronation,  and  supination  are  free.     A  slight 


i8o  ORTHOPEDIC  SURGERY. 

increase  of  surface  temperature  is  usually  found,  but  its  absence  does 
not  exclude  the  disease.  Careful  examination  will  reveal  a  slight 
amount  of  swelling  even  at  this  stage  of  the  affection,  shown  b}'  fulness 
and  thickening  on  either  side  of  the  tendon  of  the  triceps,  and,  looking 
at  the  elbow  from  behind,  the  joint  appears  broader  than  normal.  As 
in  other  joints,  wasting  of  muscles  occurs  rapidly.  As  the  disease 
progresses  the  stiffness  increases,  motion  in  other  directions  is  restricted 
and  resisted  by  muscular  spasm,  and  the  joint  is  generally  held  at  an 
obtuse  angle.  Starting  pains  may  be  added  to  the  other  symptoms, 
and  become  the  source  of  great  discomfort.  The  whole  joint  becomes 
involved  in  the  swelling,  the  enlargement  assuming  a  fusiform  shape. 

The  swelling  sometimes  becomes  very  great.  The  skin  may  be- 
come riddled  with  sinuses,  the  tuberculous  infection  attacks  the  soft 
parts,  and  the  whole  elbow  becomes  a  pulpy,  granulating  mass.  This 
occurs  in  neglected  cases  of  elbow  disease  and  also  as  the  result  of 
relapses  after  excision  of  the  joint.  Tuberculosis  of  the  head  of  the 
radius  may  exist,  in  which  case  limitation  of  rotation  and  local  swelling 
are  predominant  symptoms. 

The  prognosis  in  tuberculous  disease  of  the  elbow  is  not  favorable 
for  re-establishment  of  motion,  unless  the  affection  is  treated  at  a  very 
early  stage.  The  joint  is  so  complicated  that  the  disease  involves  a 
large  and  comparatively  widespread  surface  of  synovial  membrane  be- 
fore its  presence  is  discovered. 

Treatment. — In  tuberculous  disease  of  the  elbow  fixation  is  de- 
manded. This  is  best  furnished  by  plaster  of  Paris  or  moulded  leather, 
which  can  be  worn  for  some  weeks  and  then  be  replaced  with  little  dis- 
turbance of  the  joint.  The  frequent  readjustment  of  splints  is  objec- 
tionable in  a  sensitive  joint.  In  any  event,  a  sling  is  to  be  carefully 
worn,  which  shall  support  the  hand  and  wrist  as  well  as  the  arm,  and 
whatever  apparatus  is  used  it  is  essential  to  remember  that  the  elbow 
should  be  flexed  to  a  right  angle,  for  if  ankylosis  occurs  in  an}*  other 
position  a  useful  arm  is  not  obtained. 

When  the  j  oint  is  fixed  by  muscular  spasm  at  an  angle  greater  than 
a  right  angle,  it  will  often  be  found  possible  to  rectify  this  by  the  appli- 
cation of  a  fixation  bandage  to  the  arm  in  its  malposition.  This  so 
quiets  the  muscular  irritation  that  in  two  or  three  weeks  it  may  easily 
be  bent  up  a  little  and  by  the  application  of  a  succession  of  bandages  it 
may  often  be  brought  into  a  right-angled  position  without  the  use  of 
the  least  force. 

If  the  disease  progresses,  it  is  of  little  use  to  continue  conservative 
treatment ;  but  one  must  proceed  to  arthrectomy,  or,  better  yet,  excis- 
ion, before  amputation  becomes  the  only  measure  holding  out  any 
prospect  of  relief.  Forcible  manipulation  of  an  ank}'losed  arm  is  some- 
times useful  after  the  disease  has  ceased  to  be  active. 


TUBERCULOUS  DISEASE   OE    THE  ELBOW.  l8i 

Excision  of  tJic  clboiv  is  perhaps  indicated  earlier  in  the  course  of 
the  disease  than  is  the  case  in  any  other  of  the  larger  joints.  After 
infancy  is  passed,  operative  interference  is  indicated  whenever  it  is 
clear  that  under  expectant  treatment  the  disease  is  growing  worse. 
Under  these  conditions  the  results  are  not,  as  a  rule,  altogether  satis- 
factory, but  if  the  disease  is  allowed  to  go  on,  the  elbow-joint  becomes 
so  disorganized  that  amputation  becomes  necessary. 

Excision  is  also  indicated  for  ankylosis  in  faulty  position,  as  when 
the  elbow  is  fixed  in  a  position  of  much  more  than  a  right  angle  or  very 
sharply  flexed.  The  longitudinal  incision  is  the  most  serviceable.  The 
forearm  is  slightly  flexed,  and  the  incision,  about  three  and  one-half 
inches  long,  is  made  a  little  to  the  inner  side  of  the  median  line  over  the 
triceps  and  ulna  and  is  carried  down  to  the  bone  throughout  its  entire 
length.  The  inner  edge  of  the  divided  periosteum  is  raised  from  the 
ulna  with  the  corresponding  half  of  the  tendon  of  the  triceps,  and  the 
dissection  is  continued  with  the  knife  close  to  the  bone,  toward  the 
internal  condyle.  Much  care  must  be  taken  to  preserve  the  connection 
between  the  periosteum,  the  muscular  attachments,  and  the  internal 
lateral  ligaments.  A  similar  dissection  should  then  be  made  upon  the 
outer  side  with  the  same  precautions.  The  humerus  is  dislocated  back- 
ward through  the  wound  and  sawed  off  wherever  it  may  be  neces- 
sary. In  other  cases  it  may  be  advisable  to  use  the  keyhole  or  chain 
saw,  and  so  far  as  may  be  necessary  the  ulna  is  cleared  and  sawed 
through,  the  head  of  the  radius  being  removed  with  the  saw  or  bone 
forceps. 

In  certain  cases,  in  which  sinuses  exist,  it  may  be  better  to  adopt 
some  informal  method  of  operation,  which  will  be  suggested  by  the 
location  of  foci  by  the  .r-ray  or  by  the  direction  and  location  of  the 
sinuses  or  abscesses. 

The  after-treatment  is  similar  to  that  of  other  excisions:  complete 
rest  to  the  joint  and  fixation  in  a  right-angled  position.  This  at  first 
can  be  best  obtained  by  the  use  of  a  plaster-of-Paris  splint  applied  out- 
side of  a  large  antiseptic  dressing.  Later,  in  the  course  of  the  conva- 
lescence, bracketed  tin  or  wooden  splints  may  be  of  use;  or,  if  one  de- 
sires, the  original  plaster-of-Paris  splint  may  be  bracketed  with  strips 
of  iron. 

In  excision  for  elbow  disease,  as  a  rule,  ankylosis  is  aimed  at  as  the 
best  possible  result,  so  that  passive  motion  is  not  to  be  considered ;  if, 
however,  the  operation  is  performed  in  adults  for  ankylosis  or  injury 
and  the  ligaments  have  been  in  a  measure  fairly  preserved  during  the 
operation,  it  may  be  advisable  to  begin  passive  motion  after  a  moderate 
degree  of  firmness  in  the  tissues  has  been  reached,  as  there  is  but  little 
danger  of  a  flail  joint  and  it  is  reasonable  to  expect  that  a  certain  degree 
of  motion  at  the  joint  may  thus  be  obtained. 


1 82  ORTHOPEDIC  SURGERY. 


WRIST. 


Symptoms. — Tuberculous  disease  is  characterized  by  swelling,  heat, 
and  stiffness.  If  the  disease  is  advanced,  deformity  and  swelling  will 
be  added  to  the  other  signs.  The  hand  may  be  held  flexed  on  the  fore- 
arm at  an  angle  of  120°  to  130°,  and  this  position  is  fairly  constant. 
Swelling  appears  first  in  the  depressions  between  the  tendons.  Later, 
measurement  will  show  the  joint  to  have  increased  in  circumference, 
and  there  is  a  fulness  of  outline,  especially  on  the  dorsal  surface,  and 
in  destructive  disease  the  swelling  extends  up  on  the  forearm  and 
down  on  the  hand.  Suppuration  is  very  liable  to  occur,  and  the  course 
of  the  disease  is  usually  long  and  slow. 

In  the  matter  of  diagnosis,  it  may  be  added  that  swelling  is  always 
present,  and  that  with  the  wasting  of  the  muscles,  the  heat,  and  the 
limitation  of  motion,  it  makes  up  the  clinical  picture  of  the  disease. 

Treatment. — In  tuberculous  disease  of  the  wrist-joint  fixation  is  in- 
dicated, and  it  is  most  easily  obtained  by  the  application  of  anterior  and 
posterior  common  wooden  splints  and  carrying  the  arm  in  a  sling. 
Plaster  of  Paris  or  a  moulded  leather  splint  forms  a  more  permanent 
dressing  and  is  equally  comfortable. 

Compression  is  a  valuable  addition  to  the  treatment,  and  Bier's  con- 
gestive method,'  as  in  the  elbow  and  ankle,  may  be  of  use  in  addition 
to  the  usual  mechanical  measures. 

Excision  of  the  joint  is  indicated  in  cases  in  children  which  do  not 
make  favorable  progress  under  conservative  treatment,  in  the  cases  of 
adults  with  severe  disease,  and  is  to  be  undertaken  earlier  in  adults 
than  in  children.  The  best  result  is  either  ankylosis  or  limited  motion, 
and,  therefore,  as  much  bone  as  possible  should  be  saved.  Other 
things  being  equal,  a  loose  joint  entails  less  power  in  the  hands  and 
fingers  than  a  stiff  one. 

The  method  of  Lister  is  performed  by  a  radial  and  dorsal  incision. 
The  radial  incision  commences  at  the  middle  of  the  dorsal  aspect  of  the 
radius  at  the  level  of  the  styloid  processes.  It  is  directed  toward  the 
inner  side  of  the  metacarpo-phalangeal  articulation  of  the  thumb,  and 
on  reaching  the  radial  border  of  the  second  metacarpal  bone  it  is  carried 
downward  longitudinally  for  half  the  length  of  the  bone.  The  soft 
parts  are  detached  from  the  bones  with  the  periosteal  elevator  or  the 
blade  of  the  knife,  and  the  radial  artery  is  thrust  somewhat  outward. 
The  soft  parts  on  the  ulnar  side  are  dissected  up  as  far  as  is  practicable, 
while  the  extensor  tendons  are  relaxed  by  bending  back  the  hand. 
The  knife  is  then  entered  on  the  inner  side  of  the  arm  for  the  ulnar 
incision  two  inches  above  the  end  of  the  ulna,  and  is  carried  downward 
in  a  straight  line  as  far  as  the  middle  of  the  fifth  metacarpal  bone  at  its 
'  Freiberg:  Anier.  Jour,  of  Orth.  Surgery,  vol.  ii.,  No.  i,  p.  50. 


TUBERCULOUS  SACRO-ILIAC  DISEASE.  1S3 

palmar  aspect.  The  tendon  of  the  extensor  carpi  uhiaris  is  cut  at  its 
insertion  into  the  fifth  metacarpal  and  dissected  up  from  its  groove  in 
the  ulna,  while  the  tendons  of  the  extensors  of  the  fingers  with  the 
radius  are  left  undisturbed.  The  anterior  surface  of  the  ulna  is  cleared 
by  cutting  close  to  the  bone.  The  anterior  ligament  of  the  wrist-joint 
is  divided  and  the  junction  between  the  carpus  and  the  metacarpus  is 
cut,  the  former  being  extracted  through  the  ulnar  incision  by  bone  for- 
ceps and  the  use  of  the  knife. 

If  the  hand  is  everted,  the  articular  heads  of  tlie  radius  and  ulna 
will  protrude  at  the  ulnar  incision,  and  as  much  as  may  be  necessary  is 
then  removed.  The  metacarpal  bones  are  also  protruded  and  dealt 
with  in  the  same  way.  The  articular  surface  of  the  pisiform  bone  is 
cut  off  and  the  trapezium  is  dissected  out.  The  operation  may,  how- 
ever, be  performed  by  a  long,  single  dorsal  incision,  a  method  identified 
with  the  name  of  Langenbeck,  which  should  begin  at  the  centre  of  the 
ulnar  border  of  the  metacarpal  bone  and  the  index  finger,  and  be  car- 
ried upward  to  the  middle  of  the  dorsal  surface  of  the  epiphysis  of  the 
radius,  and  dissected  down  to  the  bone.  The  sheaths  of  the  tendons 
are  lifted  with  the  periosteum  and  carried  to  the  radial  side  of  the  long 
incision;  the  hand  is  flexed  and  the  articular  surface  of  the  upper 
row  of  carpal  bo-nes  is  exposed.  The  ends  of  the  radius  and  ulna 
may  be  denuded  and  thrust  through  the  wound  and  sawed  off  in  the 
usual  way.  Here,  as  in  other  excisions,  informal  methods  of  operating 
may  be  necessary  on  account  of  the  situation  of  abscesses  and  sinuses. 

The  operation  is  indicated  when  expectant  treatment  has  failed,  but 
the  joint  is  so  easily  fixed  and  so  accessible  that  mechanical  treatment 
works  at  good  advantage.  Operation  is  attended  with  so  much  de- 
formity of  the  wrist  and  such  doubtful  results  on  account  of  the  very 
extensive  surface  of  the  serous  membrane  that  excision  should  not  be 
lightly  undertaken.  The  after-treatment  is  simple,  because  the  hand 
can  be  kept  so  easily  at  rest  upon  a  palmar  splint ;  but  any  form  of 
splint  may  be  applied  which  will  afford  permanent  and  efficient  fixation. 
In  children  excision  should  be  done  only  in  severe  cases,  when  conserv- 
ative treatment  has  failed.  As  in  ankle-joint  excision,  the  whole  of 
every  diseased  carpal  bone  should  be  removed. 

SACRO-ILIAC    DISEASE. 

By  sacro-iliac  disease  is  meant  disease  of  the  sacro-iliac  synchon- 
drosis. This  affection  is  also  known  as  sacro-coxitis  (Hueter),  sacrar- 
throcace,  and  sacro-coxalgie. 

Disease  of  this  joint  is  a  rare  condition.     It  is  essentially  a  disease  of 

young  adult  life,  being  slightly  more  common  in  men  than  in  women.' 

It  occurs  occasionally  in  children.    Chronic  sacro-iliac  disease  is  generally 

tuberculous. 

'  Van  Hook  :  Ann.  of  Surgery,  iSSS-89. 


1 84 


ORTHOPEDIC  SURGERY. 


Etiology. — The  etiology  is  also,  in  large  part,  similar  to  that  of 
chronic  disease  of  this  type  in  other  joints;  traumatism  and  the  strain 
of  parturition  being  assigned  as  the  commonest  causes/ 

Symptoms. — In  the  early  part  of  the  disease  such  symptoms  as  a 
slight  abdominal  distress,  difficulty  in  micturition  or  in  evacuation  of 
the  bowels,  fatigue,  a  feeling  of  indisposition,  etc.,  are  often  present 
and  as  the  disease  progresses  more  pronounced  signs  appear.  Pain 
is  nearly  always  present,  and  may  vary  much  in  intensity.  It  is  made 
worse  by  standing  and  is  almost  always  relieved  by  lying  down.  It- is 
also  apt  to  be  more  severe  at  night,  and  is  increased  by  pressure  upon 
the  trochanters  or  wings  of  the  ilia.     The  pain  varies  in  situation,  and 


Fig.  172. — Sacro-iliac  Disease  (Non-tuberculous).     (Dr.  J.  E.  Goldthwait.) 

may  be  referred  to  the  course  of  the  sciatic  nerve.  Sensitiveness  upon 
pressure  over  the  joint  is  a  common  symptom,  and  this  may  be  devel- 
oped over  the  anterior  part  of  the  joint  by  palpation  through  the  rec- 
tum. Some  swelling,  or  a  boggy  feeling,  is  usually  present  about  the 
articulation,  and  if  it  goes  on  to  abscess  formation  the  fluctuating 
swelling  may  present  at  almost  any  point,  either  directly  backward  into 
the  lumbar  region,  or  it  may  become  intrapelvic,  in  which  case  it  may 
appear  in  the  groin  as  a  psoas  abscess,  or  point  in  the  ischio-rectal  fossa, 
or  at  either  of  the  sacro-sciatic  notches.  Limping  is  practically  always 
present. 

The  position  of  the  body  in  walking  or  standing  is  fairly  characteris- 
tic, the  weight  of  the  trunk  being  thrown  upon  the  well  foot,  while  the 
other  leg  hangs  down ;  this  exerts  a  slight  extension  by  its  weight.     In 
' "  Ref.  Handbook  of  the  Med.  Sciences,"  vol.  vi.,  p.  240. 


TUBERCULOUS  SACRO-ILIAC  DISEASE.  185 

walking  the  gait  is  very  cautious,  all  jar  is  avoided,  and  hence  the  toe  is 
largely  used  instead  of  the  flat  of  the  foot  on  the  diseased  side.  Atrophy 
of  the  muscles  of  the  leg  upon  the  affected  side  is  usually  present,  and 
is  seen,  as  in  other  chronic  joint  affections,  quite  early  in  the  disease. 

Diagnosis. — Sacro-iliac  disease  has  been  mistaken  for  sciatica,  but 
aside  from  the  fact  that  the  latter  is  usually  found  later  in  life,  the 
pains  are  not  relieved  by  the  recumbent  position.  * 

In  lumbago  the  pain  is  more  diffuse  and  higher  up  than  in  disease 
of  the  sacro-iliac  articulation. 

Inflammation  of  the  psoas  muscle  (psoitis)  more  usually  simulates 
hip  disease,  but  it  may  be  mistaken  for  sacro-iliac  disease.  In  this 
there  is  no  tenderness  over  the  joint  and  the  pain  which  is  present  is 
increased  by  extension  of  the  thigh,  while  flexion  relieves  it. 

Positive  diagnosis  of  sacro-iliac  disease  from  hip  disease  and  Pott's 
disease  in  the  lumbo-sacral  region  is  at  times  difificult  and  often  impos- 
sible, especially  in  the  class  of  cases  just  referred  to.  In  hip  disease 
all  manipulation  is  resisted  by  muscular  spasm,  while  in  sacro-iliac  dis- 
ease, with  the  iliac  bones  held  firmly,  all  motions  at  the  hip  are  possible 
without  pain.  Also  in  hip  disease  the  pain  is  never  increased  by  press- 
ure upon  the  wings  of  the  ilia  as  is  the  case  in  sacro-iliac  inflamma- 
tion. In  Pott's  disease  we  have  a  prominence  of  some  of  the  spinous 
processes  with  rigidity  of  the  spine  when  motion  is  attempted,  and 
local  tenderness  is  not  present  over  the  sacro-iliac  articulation,  nor  does 
pressing  together  the  ilia  cause  pain. 

Prognosis. — The  prognosis  in  this  disease  is  at  best  quite  grave. 
Patients  do  recover,  but  it  is  one  of  the  most  chronic  of  joint  affections, 
and  usually  goes  on  to  abscess  formation,  with  prolonged  suppuration 
and  death  either  from  exhaustion,  or  renal  complications,  or  secondary 
tuberculosis. 

Treatment. — The  principles  of  treatment  are  the  same  as  in  all 
chronic  joint  affections.  In  the  acute  stage  the  patient  should  be  kept 
upon  the  back  in  bed,  with  weight-and-pulley  extension  to  the  leg  to 
steady  the  limb,  and  as  the  acute  symptoms  abate  he  may  be  allowed 
to  go  about  on  crutches,  with  a  high  sole  upon  the  well  foot,  the  weight 
of  the  other  leg  serving  as  extension.  While  moving  about,  a  certain 
amount  of  comfort  may  be  derived  from  a  swathe,  of  either  leather,  or 
adhesive  plaster,  or  plaster  of  Paris,  about  the  pelvis,  which  serves  in 
part  to  fix  the  joint. 

When  an  abscess  has  formed  it  should  at  once  be  laid  open,  any 
diseased  bone  removed,  and  treated  like  any  cold  abscess.  When  the 
abscess  is  intrapelvic  it  may  be  quite  difficult  to  reach.  Excision  of  the 
sacro-iliac  synchondrosis  may  be  done  in  severe  cases. 

In  all  of  these  cases  tonics  and  constitutional  treatment  are  not  to 
be  neglected. 


CHAPTER    VI. 

INFECTIOUS     OSTEOMYELITIS  —  INFECTIOUS 
SYNOVITIS   AND   ARTHRITIS. 

Infectious  osteomyelitis  (Etiology.— Pathology.—  Symptoms.— Diagnosis.— Dif- 
ferential diagnosis. — Prognosis.— Treatment).— Spine. — Typhoid  spine. — Hip. 
—Acute  arthritis  of  infants. — Infectious  synovitis  and  arthritis  (Etiology.— Pa- 
thology.—Treatment). —  Gonorrhceal  arthritis  (Varieties. —  Pathology.—  Etiol- 
ogy.— Treatment). 

INFECTIOUS   OSTEOMYELITIS. 

This  process/  primarily  attacking  the  bones  and  at  times  seconda- 
rily affecting  the  joints,  is  the  result  of  an  infection  by  some  pyogenic 
bacterium.  It  attacks  preferably  the  diaphysis  of  the  long  bones,  gen- 
erally near  the  epiphysis,  and  as  a  rule  one  bone  only  is  attacked,  but 
in  exceptional  cases  several  may  be  involved.  It  occurs  usually  in  bone 
which  has  not  become  fully  developed.  If  it  is  confined  to  the  shaft  of 
the  bone  the  joints  are  not  involved,  but  when  it  is  located  near  the 
ends  of  the  bone  the  joints  are  frequently  invaded. 

Etiology. — The  organism  most  frequently  found  is  the  staphylococ- 
cus pyogenes  aureus,'  although  the  aureus  and  the  citreus  are  some- 
times present.  The  lesions  produced  by  this  organism  are,  as  a  rule, 
the  most  typical  and  extensive.  The  streptococcus  pyogenes  '  is  less 
commonly  seen  and  the  lesions  caused  by  it  are  more  liable  to  attack 
the  periosteum  and  the  superficial  part  of  the  bone,  to  cause  separation 
of  the  epiphysis,  and  to  involve  the  joints.  The  pneumococcus  at  times 
is  the  cause  of  a  process  indistinguishable  from  that  caused  by  the 
streptococcus.*  The  typhoid  '  bacteria  may  cause  suppuration  in  bone, 
usually  in  small  and  superficial  areas,  unless  a  secondary  infection  with 
some  other  organism  is  present.  Secondary  infections  with  other  or- 
ganisms have  been  reported.  The  femur,  the  tibia,  and  the  humerus 
"are  the  bones  most  commonly  attacked. 

Infectious  osteomyelitis  is  not  a  specific  disease,  but  the  result  of 
infection  by  one  of  a  variety  of  pathogenic  organisms,  and  it  has  been 

^E.  H.  Nichols:  Journal  Am.  Med.  Assn.,  1904. 

'^  Lannelongue  :  Revue  de  Chir.,  1895. — Lannelongue  and  Achard :  Arch,  de 
M^d.  exp.  et  d'Anat.  path.,  1S92. 

^  Lexer  :  Volkmann's  kl.  Vort. ,  N.  F.,  173,  p.  659. 
*  Fischer  and  Levy:  Deut.  Zeit.  f.  Chir.,  1893. 
=  Keen  :  "  Surg.  Compl.  of  Typhoid  Fever,"  1898. 

186 


INFECTIO  US   OS  TEOM  YELITIS. 


iS: 


produced  experimentally.'  As  a  rule  it  occurs  at  or  shortly  after  the 
age  of  puberty,  although  young  children  are  often  infected  and  adults 
are  not  exempt ;  it  occurs  more  frequently  in  boys  than  in  girls.  The 
affection  may  arise  in  the  bone  without  evidence  of  disease  in  other  tis- 
sues, the  organism  finding  its  entrance  through  an  unknown  or  appar- 
ently insignificant  source  of  infection.  The  disease  appears  frequently 
after  trauma,  extreme  fatigue,  and  exposure  to  cold  and  wet ;  it  also 
occurs  secondarily  to  a  previous  disease,  such  as  typhoid  fever,  scarlet 
fev^er,  or  similar  infectious  disease.  At  other  times  it  is  secondary  to  a 
local  infection  in  some  other  part  of  the  body,  such  as  furuncle,  car- 
buncle, erysipelas,  septicaemia, 
pleurisy,  pneumonia,  or  em- 
pyema. 

Pathology. — The  bone  mar- 
row is  the  part  primarily  attacked. 
The  trabeculae  and  cortex  are  at 
first  but  slightly  involved,  though 
later  extensive  destruction  may 
take  place.  The  process  may 
spread  extensively  in  the  marrow 
before  it  pierces  the  cortex,  where 
it  extends  and  causes  suppuration 
between  the  bone  and  periosteum 
and  later  in  the  soft  tissues,  de- 
veloping an  abscess  which  may 
evacuate,  with  the  establishment 
of  a  sinus  leading  to  necrosed 
bone.  If  the  periosteum  has 
been  extensively  separated  from 
the  cortex,  extensive  necrosis 
of  the  shaft  follows,  surrounded 
by  a  formation  of  dense  cicatri- 
cial bone.  As  a  rule  the  proc- 
ess does  not  extend  to  the  epiphysis,  but  there  may  be  a  complete 
destruction  of  the  epiphyseal  line  and  a  separation  of  the  epiphysis. 
When  ossification  has  obliterated  the  epiphyseal  line  the  process 
may  extend  to  the  joint,  being  checked  temporarily  by  the  carti- 
lage, but  subsequently  invading  the  joint,  with  joint  destruction.  De- 
formities develop  as  a  result,  but  even  when  joint  destruction  has  not 
taken  place  deformity  may  result  from  the  destructive  changes  in  the 
soft  parts  adjacent  to  the  joint,  which  cause  impairment  of  motion, 
ankylosis,  and  displacement  of  joint  surfaces.     When  contiguous  por- 

'  Le.xer:    Deutsch.  med.  Woch.,  xvi.,  1894. — Ackerman :  Arch,  de  Mdd.  exp. 
et  d'Anat.  path.,  1S95. 


Fig.   173.— Acute   Infectious   Osteomyelitis  of 
Tibia  Involving  Knee-joint. 


1 88  ORTHOPEDIC  SURGERY. 

tions    of    bone   are    destroyed    by   necrosis    extensive    deformity    may 
result. 

Symptoms. — The  affection  begins  suddenly  with  severe  general  dis- 
turbances, accompanied  by  pain  in  the  affected  bone,  often  in  the  vicin- 
ity of  a  joint  which  is  held  rigid  on  account  of  the  pain.  The  attack 
may  be  of  great  severity  and  the  symptoms  may  resemble  those  of 
typhoid,  thus  masking  the  local  symptoms.  At  other  times  the  attack 
is  much  less  severe,  the  general  symptoms  being  those  of  a  moderate 
general  infection.  As  a  rule  the  local  symptoms  are  of  moderate  sever- 
ity, and  in  addition  to  the  pain  there  are  present  swelling  and  tender- 
ness of  the  parts  about  the  affected  bone,  elevation  of  temperature  of 
a  greater  or  less  degree,  increase  of  pulse,  and  symptoms  of  sepsis  in  a 
degree  varying  with  the  severity  of  the  case.     Increased  leucocytosis  is 


Fig.  174.— Acute  Osteomyelitis  of  the  Knee-joint. 

present  and  delirium  in  the  severer  cases.  This  stage  of  onset,  espe- 
cially when  of  moderate  severity,  may  be  overlooked  by  the  attendants 
of  the  patient,  whose  attention  is  centred  on  the  severity  of  the  local 
symptoms.  If  the  disease  is  left  unrelieved  the  condition  becomes  rap- 
idly worse,  in  the  severer  cases  markedly  septic  symptoms  appearing. 

Diagnosis — The  diagnostic  signs  of  the  condition  are  rapid  onset, 
marked  rise  of  temperature,  mild  or  severe  symptoms  of  sepsis,  in- 
creased leucocytosis,  and  signs  of  a  severe  inflammatory  process  over 
"the  end  of  one  of  the  long  bones.  In  the  early  stage  the  ,t--ray  does 
not  afford  a  means  of  diagnosis. 

Differential  Diagnosis. —  Typhoid  Fever. — The  initial  stage  of  a  se- 
vere type  of  the  affection  may  be  confounded  with  typhoid  fever.  In 
the  latter,  however,  the  bone  symptoms  when  they  occur  are  late  and 
of  less  severity,  and  on  careful  examination  cases  of  osteomyelitis  will 
be  found  to  lack  the  characteristic  diagnostic  signs  of  typhoid,  the 
resemblance  being  only  superficial. 

Rheumatism. — The  less  severe  grades  of  the  affection  are  frequently 


INFECTIOUS    OSTEOMYEIITIS.  189 

diagnosticated  as  rheumatism.  The  rapid  development  of  osteomyeU- 
tis,  the  septic  character  of  the  symptoms,  the  severe  localized  pain,  and 
the  development  of  a  process  evidently  suppurative  will  in  most  cases 
suffice  to  differentiate  the  two. 

Tiibefculous  Disease. — In  the  mild  cases  the  resemblance  to  an 
acute  degree  of  tuberculosis  of  the  joint  is  not  infrequent.  The  process 
is,  however,  more  acute  and  severe,  the  temperature  is  higher,  leuco- 
cytosis  is  more  constantly  present,  and  although  in  certain  cases  the 
diagnosis  is  one  of  difficulty,  it  can  ordinarily  be  made  by  a  careful 
examination  on  the  lines  indicated  in  speaking  of  the  two  affections. 

Prognosis. — In  the  severer  types  of  this  affection  the  condition  is 
grave  and  the  danger  of  septicaemia  is  considerable.  The  prognosis 
depends  in  a  measure  on  the  stage  of  the  infection  at  which  operative 
relief  is  afforded.  In  the  less  severe  cases  a  stage  of  extreme  pain  per- 
sisting for  some  weeks  is  followed  by  abscess  development  with  necrosis 
and  the  establishment  of  sinuses.  When  the  affection  is  near  the  joint 
in  young  children  the  liability  to  dislocation  and  separation  of  the  epiph- 
ysis is  to  be  borne  in  mind.  Young  infants,  who  are  frequently  af- 
fected, in  the  majority  of  cases  make  good  recoveries  with  early  opera- 
tive treatment.  The  motion  of  the  joint  is  not  necessarily  lost  where 
early  operation  is  undertaken,  but  ankylosis  is  commonly  an  outcome 
of  the  severe  grades  of  the  condition. 

Treatment. — The  treatment  varies  with  the  stage  of  the  disease. 
In  the  acute  stage  if  the  symptoms  are  at  all  severe  the  indication  is  to 
cut  down  upon  the  diseased  area,  to  wash  out  the  diseased  tissue,  or  to 
establish  drainage.  As  the  focus  is  in  the  marrow,  the  cortex  of  the 
bone  is  to  be  trephined  until  the  marrow  is  reached  and  drainage  estab- 
lished. Where  exact  localization  is  not  possible  the  bone  can  be  tre- 
phined in  the  diaphysis  near  the  epiphyseal  line.  The  marrow  should 
not  be  curetted,  as  it  is  desirable  to  save  the  endosteum.  If  the  symp- 
toms are  slight  it  may  be  safe  to  delay  active  interference,  but  judgment 
should  favor  incision  and  drainage  in  all  doubtful  cases. 

In  the  subacute  stage  it  is  desirable  to  remove  the  necrotic  area  to 
establish  the  regeneration  which  takes  place  through  the  periosteum. 
The  periosteum  should  be  separated  from  the  bone,  and  in  cases  with 
extensive  disease  the  diseased  shaft  removed  and  the  inner  edges  of  the 
periosteum  placed  in  apposition,  to  favor  the  formation  of  new  bone. 
The  removal  of  this  necrotic  portion  should  not  be  attempted  until  the 
acute  stage  has  passed,  usually  about  two  months  after  the  first  onset 
of  the  disease. 

In  the  chronic  stage  the  treatment  involves  the  consideration  of  not 
only  the  removal  of  the  sequestrum,  but  the  filling  of  the  remaining 
cavity  with  normal  bone.  As  the  cavity  is  surrounded  by  thick,  hard 
bone  with  little  vascularity,  it  does  not  readily  develop  new,  healthy 


1 90  ORTHOPEDIC  SURGERY. 

bone  growth.     Sinuses  persist  indefinitely,  the  cavitv  being  filled  with 
granulation  tissue  (Nichols).' 

The  removal  of  the  shaft  as  well  as  the  sequestrum  and  stitching 
the  surfaces  of  the  uppermost  sides  together  is  indicated.  In  the 
tibia,  where  the  fibula  acts  as  a  splint,  this  can  be  done,  but  where  no 
splint  of  bone  is  present  a  part  of  the  involucrum  must  be  left.  The 
periosteum  should  be  applied  closely  to  it,  regeneration  of  bone  taking 
place  from  the  inner  surface  of  the  periosteum  and  from  healthy  endos- 
teum . 

AMien  the  joint  is  involved  the  treatment  is  conducted  on  the  same 
principles.  In  the  acute  stage  drainage  should  be  established  as  soon 
as  possible  by  free  incisions.  In  the  subacute  stage  where  no  sinus 
has  been  established  the  joint  will  need  iixation  and  protection  to  check 
the  progress  of  the  disease  and  to  prevent  deformity.  The  treatment 
under  the  circumstances  resembles  that  given  in  tuberculous  joint 
affections.  In  the  chronic  stage  with  sinuses  and  sequestra,  the  treat- 
ment consists  of  the  thorough  drainage  of  bone  with  the  free  removal 
of  the  hardened  bone.  If  the  cavit\"  necessarv  for  complete  drainage  is 
a  large  one,  it  can  be  left  to  till  ni  with  granulation  or  can  be  covered 
in  with  a  periosteal  llap. 

The  treatment  of  the  deformities  following  infectious  osteom\'elitis  - 
is  similar  to  that  of  the  deformities  following  tuberculous  ostitis.     Forci- 
ble rectification  of  contracted  joints,  with  or  without  osteotomv  or  in- 
cision, may  be  needed.      Such  operative  interference  should  not   be 
undertaken  until  the  stage  of  cicatrization  has  been  established. 

Spixe. 

Acute  Osteomyelitis. — The  spine  is  not  commonly  attacked  by  this 
disease.  In  1903  about  fifty  well-authenticated  cases  had  been  re- 
ported." 

The  most  common  age  of  onset  is  from  six  to  fifteen,  but  vounger 
children  and  adults  are  not  exempt.  The  process  mav  attack  either  the 
vertebral  arches  or  the  bodies,  and  is  of  the  same  general  character  as 
osteomyelitis  elsewhere,  modified  by  the  peculiar  structure  of  the  ver- 
tebral column.  It  occurs  under  the  same  conditions  as  those  of  the 
general  process.  Secondary  centres  of  suppuration  are  likelv  to  occur 
elsewhere  in  the  body.  The  lumbar  region  is  most  frequentlv  affected, 
but  no  part  of  the  spine  is  exempt." 

The  symptoms  are  stiffness,  tenderness  and  pain,  high  fever,  and 
much  constitutional    disturbance.      Abscess  occurs    in  practicallv  all 

'Journal  of  the  Amer.  ]\Ied.  Assn..  February  13th.  1904. 
-Grisel:  Re^-ue  d"Orthopedie.  September.  1903. 

® Gross:  "Osteomyelitis  of  the  Lateral  Parts  of  the  Sacrum."  Deutsch.  Zeit. 
f.  Chir..  Ixviii  ,  95. 


INFECTIOUS   OSTEOMYELITIS.  191 

cases  and  the  tissues  around  the  abscess  become  oedematous.  Al- 
though posterior  abscesses  are  accessible,  anterior  abscesses  are  almost 
impossible  to  locate.     Paralysis  occurs  in  about  one-third  of  the  cases. 

Deformity  of  the  spine  is  not  of  frequent  occurrence,  because,  al- 
though the  process  is  rapidly  destructive,  the  new  formation  of  bone  is 
rapid  and  the  severity  of  the  disease  necessitates  recumbency. 

The  mortality  has  been  said  to  be  as  high  as  sixty  per  cent,  but  this 
cannot  be  accepted  as  accurate,  as  the  less  severe  forms  of  the  affection 
may  often  have  been  overlooked. 

Direct  incision  to  the  bone  furnishing  drainage  is  indicated  as  soon 
as  is  possible.  During  convalescence  the  spine  should  be  supported  as 
in  Pott's  disease. 

Typhoid  Spine. — In  the  later  stages  of  typhoid  fever  an  acute,  pain- 
ful condition  of  the  spine,  presenting  symptoms  similar  to  those  of 
very  acute  Pott's  disease,  occasionally  is  seen.  Although  pathological 
proof  is  wanting,  it  seems  likely  that  the  affection  is  a  localized  and 
often  superficial  osteomyelitis  of  the  vertebral  column.  The  nervous 
symptoms  are  most  marked,  and  disturbances  of  sensation  and  paraes- 
thesia  are  frequently  present.  Deformity  is  not  the  rule  and  when  it 
occurs  is  small  in  extent.  The  prognosis  for  ultimate  recovery  is  good 
and  the  treatment  does  not  differ  from  that  of  acute  Pott's  disease.' 

Hip. 

Acute  Osteomyelitis. — This  location  of  osteomyelitis  is  compara- 
tivel}"^  frequent.  In  758  cases  of  disease  of  the  hip  at  the  Gottingen 
Clinic,"  there  were  no  cases  of  acute  infection  and  568  cases  of  tubercu- 
losis.    This  proportion  is  practically  the  same  as  that  found  by  Bruns.' 

The  process  may  be  acute  and  rapidly  destructive  or  slower  and  less 
acute. 

In  infants  it  is  rather  a  violent  process,  accompanied  by  high  fever 
and  much  swelling  about  the  hip.  Pain  and  constitutional  disturbance 
are  marked.  Flexion  of  the  limb  and  muscular  spasm  are  pronounced 
and  abscess  occurs  in  most  if  not  all  cases.  The  process  may  cause 
separation  of  the  epiphysis  of  the  femur,  destruction  of  the  head  of  the 

'Konitzer:  Miinchener  medicinische  Wochenschrift,  August  29th.  1899(46 
Jahrg.,  No.  35).  Philadelphia  Medical  Journal,  February  loth,  1900. — Frederick 
T.  Lord:  "Analysis  of  Twenty-six  Cases  of  Typhoid  Spine"  (with  literature). 
Boston  Medical  and  Surgical  Journal,  June  26th,  1902. — R.  W.  Lovett  and  C.  F. 
Withington :  Boston  Medical  and  Surgical  Journal,  March  29th,  1900. — E.  G.  Cut- 
ler: Boston  Medical  and  Surgical  Journal,  June  26th,  1902,  p.  6S7. — E.  Fraenkel : 
"  Ueber  Erkrankungen  des  rothen  Knochenmarks,  besonders  der  Wirbel,  bei  ab- 
dom.  Typhus,"  Hamburg.  Mittheilungen  a.  d.  Grenzgebieten.  Jena. — Journal  of 
the  American  Medical  Association.  April  25th,  1903. 

'-'  Konig:  "  Die  spec.  Tub.  der  Knochen  u.  Gelenke,"  .xi.,  Berlin.  1902. 

"Brunsand  Honsell:  Beitr.  z.  klin.  Chir. ,  xxiv. ,  i;  .xx.xix.,  3. 


192  ORTHOPEDIC  SURGERY. 

femur,  or  dislocation  of  the  hip  by  destruction  of  the  capsule  without 
destruction  of  the  head.  In  the  latter  cases  the  disease  of  the  bone  is 
probably  situated  a  little  farther  from  the  articular  surface.  In  each 
of  these  conditions  the  hip  is  found  completely  dislocated  with  perhaps 
grating  in  the  joint.  In  such  cases  later  in  life  a  condition  resembling 
congenital  dislocation  of  the  hip  is  found  where  the  stump  of  the  femur 
is  loosely  connected  with  the  acetabulum.  This  condition  is  spoken  of 
as  floating  pseudoarthrosis  or  pseudoarthrose  fiottaiite.^  Extensive 
osteomyelitis  of  the  femur  may  remain  after  the  hip  symptoms  have 
been  relieved  by  operation. 

In  older  children  the  process  is  less  violent  and  bears  more  resem- 
blance to  tuberculosis  of  the  hip  in  its  clinical  aspect.  The  symptoms 
are,  however,  more  severe.  It  is  attended  by  high  fever,  leucocytosis, 
and  perhaps  delirium;  there  is  much  swelling,  and  the  joint  symptoms 
are  of  a  very  marked  character.  Shortening  may  occur  rapidly  and 
abscess  is  practically  universal.  In  some  cases  the  affection  is  less 
acute,  and  in  these  the  diagnosis  from  tuberculosis  often  cannot  be 
made  until  the  abscess  is  opened  and  a  culture  made  from  its  contents. 

Coxa  vara  may  result  from  the  faulty  union  of  a  loosened  epiphysis 
or  from  a  spontaneous  fracture  of  the  neck. 

The  treatment  of  the  disease  does  not  differ  from  that  of  osteomye- 
litis in  other  joints.  The  hip-joint,  however,  may  require  traction  or 
protection  after  operation. 

In  other  joints  the  affection  presents  no  peculiar  characteristics. 

Acute  Arthritis  of  Infants. 

This  condition,  recognized  clinically  since  its  description  by  Thomas 
Smith  in  1874,'  is  now  identified  as  a  variety  of  osteomyelitis  affecting 
the  joints  in  young  infants,  the  exact  pathological  history  of  which  is 
not  known.  The  onset  is  severe  and  is  characterized  by  elevation  of 
temperature,  marked  general  disturbance,  and  local  swelling  about  the 
joint,  which  is  quickly  followed  by  suppuration,  the  formation  of  an 
abscess,  and  disorganization  of  the  joint,  with  extensive  destruction  of 
tissue  unless  the  process  is  arrested  by  early  operation.  Spontaneous 
evacuation  of  the  abscess  may  occur.  In  the  severer  cases  separation 
of  the  epiphysis,  dislocation,  or  the  formation  of  a  flail  joint  may  result. 
Death  may  occur  from  septicaemia,  and  the  prognosis  is  not  so  good  in 
cases  in  which  more  than  one  joint  is  affected.  The  prognosis  depends 
more  upon  the  performance  of  an  early  effective  operation  than  on 
anything  else.     The  death  rate  has  been  variously  given,'  but  recovery 

^  Ducroquet  et  Besanqon  :  Presse  ^led.,  No.  15.  1903. 
-  St.  Bartholomew's  Hosp.  Reports,  vol.  x.,  1S74. 

^Gonser:  Jahrb.  f.  Kinderh.,  July,  1902.— Hoffmann :  Med.  Bull.  Wash, 
Univ..  September.  1902.— Whitman  :  "  Orth.  Surg.."  2d  ed..  p.  271. 


INFECTIOUS  SYNOVITIS  AND  ARTHRITIS.  193 

frequently  occurs  in  cases  in  which  early  operation  is  possible.  Treat- 
ment should  consist  in  free  incision  and  flushing  out  of  the  affected 
joint  with  free  drainage.  The  operation  should  be  followed  by  fixation 
until  the  wound  is  closed.  The  hip  and  knee  are  the  joints  commonly 
affected. 

INFECTIOUS    SYNOVITIS    AND    ARTHRITIS. 

An  inflammation  of  the  joints  may  occur  in  connection  with  acute 
infectious  diseases,  which  may  be  acute  or  chronic,  serous  or  purulent. 

Etiology. — The  lesions  which  occur  are  to  be  attributed  to  the  pres- 
ence in  the  joints  of  micro-organisms  or  their  products,  and  the  organ- 
isms found  in  the  joints  are  either  the  staphylococcus,  the  streptococ- 
cus, or  the  organism  peculiar  to  the  primary  disease.  The  affection 
may  involve  one  or  several  joints,  and  attacks  children  more  commonly 
than  adults. 

The  infectious  diseases  in  which  joint  complications  occur  '  are  as 
follows:  Cerebro-spinal  meningitis,  diphtheria,  dysentery,  erysipelas, 
epidemic  parotitis,  glanders,  gonorrhoea,  epidemic  influenza,  measles, 
pneumonia,  pertussis,  puerperal  fever,  pyaemia,  septicaemia,  scarlet 
fever,  smallpox,  tonsillitis,  typhus  fever,  typhoid  fever,  after  the  use  of 
sounds  and  catheters,  and  possibly  in  malaria.  An  affection  of  the 
joints  of  a  similar  character  is  seen  at  times  where  no  antecedent  infec- 
tious disease  can  be  identified. 

In  the  same  connection  must  be  mentioned  pyogenic  infection  of 
the  joints  from  wounds  and  similar  outside  sources. 

In  consequence  of  some  of  the  above-mentioned  infections  there 
arises  a  joint  affection  of  another  type,  not  to  be  distinguished  clinically 
from  arthritis  deformans.^     It  will  be  considered  in  that  connection. 

Pathology. — The  affection  is  most  often  manifested  by  an  acute 
serous,  sero-puralent,  or  purulent  inflammation  of  the  joint,  accompa- 
nied at  times  by  a  deposit  of  fibrin.  The  process  is  generally  most 
evident  in  the  synovial  membrane,  and,  although  bony  involvement  by 
extension  may  occur,  it  is  not  the  rule.  In  purulent  cases  there  is  sup- 
puration of  the  synovial  membrane  with  loss  of  epithelium,  and  in  se- 
vere cases  the  formation  of  granulation  tissue,  fibrous  degeneration,  or 
even  necrosis  of  the  cartilage  and  damage  to  the  ends  of  the  bones  and 
destruction  of  the  ligaments.  Spontaneous  luxations  may  occur  and 
ankylosis  must  result  in  the  severest  cases.  In  a  great  part  of  the  cases, 
however,  the  local  process  runs  its  course  without  great  damage,  and 
even  in  suppurative  cases  early  incision  is  usually  resorted  to  before  the 
process  has  accomplished  extensive  destruction.  Less  commonly  these 
processes  are  chronic  or  subacute. 

^  For  literature  see  second  edition  of  tliis  boolv,  p.  194. 
-J.  E.  Goldthwaite  :  Boston  Med.  and  Surg.  Journ..  1904. 
13 


194  ORTHOPEDIC  SURGERY. 

Symptoms. — The  symptoms  vary,  according  to  the  grade  and  char- 
acter of  the  infection,  from  those  of  a  simple  synovitis  to  those  of  a 
severe  suppurative  process. 

Treatment. — In  the  milder  cases  the  treatment  is  that  of  synovitis. 
In  suppurative  cases  the  joint  should  be  freely  opened,  washed  out, 
and  drained  as  soon  as  the  existence  of  suppuration  is  recognized. 

The  only  modification  of  the  usual  free  incisions  in  general  use  is 
to  be  found  at  the  knee-joint,  in  which,  in  severe  cases,  it  may  be  found 
advisable  to  make  an  extensive  U-shaped  incision,  cut  the  patella  ten- 
don across,  and  fix  the  knee  in  a  flexed  position  after  the  method  of 
Mayo.  In  this  way  the  joint  is  thoroughly  drained.  The  patella  ten- 
don is  sutured  when  repair  is  established. 

GONORRHCEA. 

Gonorrhoeal  synovitis  or  arthritis,  and  gonorrhoeal  rheumatism  are 
the  names  most  commonly  applied  to  an  inflammation  of  the  joints 
occurring  in  the  later  stages  of  gonorrhoea. 

This  inflammation  is  acute  or  chronic,  and  is  most  often  polyarticu- 
lar.' 

Varieties. — The  commonest  inflammations  are  as  follows : 

Arthralgia,  without  definite  lesions  or  associated  with  slight  periar- 
ticular lesions  or  bursitis. 

Acute  synovitis,  monarticular  or  polyarticular,  resembling  acute 
rheumatism,  with  considerable  periarticular  swelling. 

Pm«r/zrz//rtr  inflammation  with  joint  effusion  absent  or  subordinate. 

Tenosynovitis  occurring  about  the  joints,  but  not  necessarily  in- 
volving them. 

CJn^onic  synovitis,  serous  or  purulent,  occurring  as  a  sequel  to  the 
acute  forms  or  begins  as  a  chronic  affection.  This,  if  prolonged,  may 
lead  to  changes  in  the  joint,  such  as  laxity  of  ligaments,  etc. 

Pathology. ^ — The  effusion,  if  serous,  is  generally  thick  and  may  con- 
tain clots  of  fibrin.  It  may  be  sero-purulent  or  purulent.  The  effusion 
may  be  colored  by  blood.  In  the  severer  cases  the  joint  changes  may 
not  differ  from  those  described  in  the  arthritis  due  to  pyasmic  processes.^ 
The  striking  feature  is  the  amount  of  granulation  tissue  formed.  Such 
a  process  shows  little  tendency  to  involve  bone  or  cartilage,  being  essen- 
tially synovial.  Ankylosis  is  to  be  feared.  The  inflammation  shows 
the  same  tendency  toward  fibrous  hyperplasia  in  the  joints  that  it  does 
in  the  urethra,  which,  of  course,  tends  to  impair  joint  motion. 

Etiology. — The  affection  has  been  demonstrated  to  be  due  to  the 
gonococcus.  The  gonococci  are  found  in  the  joint  effusion  in  many 
cases.     They  are  more  likely  to  be  found  in  acute  than  in  chronic 

^  Trans.  Assn.  Am.  Physicians,  vol.  x.,  p.  150. 
-Wien.  klin.  Woch.,  January  15th  and  22d,  1903. 


INFECTIOUS  SYNOVITIS  AND  ARTHRITIS.         195 

cases.  The  gonococci  may  be  present  in  the  pus  cells  of  the  granula- 
tion tissue,  or  if  in  the  exudate,  in  phagocytes  or  in  epithelial  cells  free 
or  in  clumps.  They  may,  however,  not  be  found  in  the  effusion  or  in 
sections  of  the  synovial  membrane.  A  mixed  infection  with  pyogenic 
organisms  may  be  found,  or,  rarely,  pyogenic  organisms  alone  may  be 
found  in  the  joint  fluid.  Suppuration  of  the  joint  is  not  necessarily 
associated  with  mixed  infection. 

Men  are  much  more  frequently  affected  than  women.  The  compli- 
cation rarely,  if  ever,  occurs  before  the  third  week  of  the  disease,  and 
occurs  in  about  two  per  cent  of  all  cases.  Involvement  of  the  joints 
may  occur  after  the  passage  of  a  sound  into  the  urethra,  in  the  vulvo- 
vaginitis of  little  girls,  and  in  the  gonorrhoeal  ophthalmia  of  babies.' 

The  joints  affected  were  as  follows  in  the  order  of  their  frequency 
in  Northrup's  series:  Knee,  91;  ankle,  57;  small  joints  of  foot,  40; 
wrist,  27;  heel  and  toes,  21;  elbow,  18;  hip,  16;  shoulder,  16;  small 
joints  of  hand,  11 ;  sterno-clavicular  joint,  3  ;  temporo-maxillary  joint,  2. 

The  prognosis  can  hardly  be  formulated.  The  affection  is  always 
serious  and  generally  slow  in  progress  and  resistant  to  medication.  In 
the  acute  stages  suppuration  is  to  be  feared,  and  impairment  of  motion, 
perhaps  ankylosis,  is  not  unlikely  to  result.  Simple  cases  perhaps  oft- 
enest  recover  after  a  long  time  with  practically  normal  motion. 

The  duration  in  Northrup's  cases  was : 

Cases. 

One  to  six  weeks 64 

Six  weeks  to  two  months 54 

Two  months  or  more 77 

Indetinite 57 

Treatment.  —  In  the  acute  stage  the  affection  should  be  treated  like 
other  forms  of  synovitis  and  the  fluid  withdrawn  from  time  to  time  for 
examination.  Suppuration  demands  incision  and  drainage.  Convales- 
cent cases  should  be  treated  as  if  convalescent  from  ordinary  synovitis, 
only  with  greater  care. 

Obstinate  and  persistent  chronic  synovitis,  if  in  the  hip,  should  be 
treated  by  protection,  and  perhaps  traction  by  apparatus.  Fixation  by 
plaster  bandages  is  to  be  used  if  the  joint  is  painful.  More  accessible 
joints  are  best  treated  by  free  incision  and  flushing  out  with  hot  sterile 
water  or  hot  weak  corrosive  solution  in  obstinate  cases.  Drainage  for 
a  few  days  should  be  kept  up  by  strips  of  gauze,  and  the  joint  should  be 
washed  out  daily  in  severe  cases.  In  such  cases  incision  and  drainage 
are  often  followed  by  cessation  of  pain  and  marked  improvement. 

If  operation  is  not  practicable  the  ordinary  measures  in  use  for  the 
treatment  of  chronic  synovitis  are  to  be  used. 

'  Editorial.  Am.  Medicine,  April  25th,  1903. — R.  B.  Kimball:  "  Gonorrhoea  in 
Infants."     Med.  Record,  November  14th.  1903. 


CHAPTER    VII. 
ARTHRITIS    DEFORMANS. 

Definition. —  Pathology. — Etiology. — ^Symptoms. — Varieties. — Frequency. — Diag- 
nosis.—  Prognosis. — Treatment. 

Spine.  — Spondylitis  Deformans. — Pathology  and  etiology. — Symptoms.— Diagno- 
sis.— Prognosis.- — Treatment. 

Hip. — Etiology  and  Pathology. — Symptoms. — Diagnosis. — Treatment. 

Knee. — Symptoms. — Prognosis. — Treatment. 

Shoulder. — Wrist.  — Temporo-maxillarj'  joint. 

The  affection  is  known  by  a  multiplicity  of  names,  of  which  the  fol- 
lowing are  the  principal  ones:  Arthritis  deformans,  rheumatic  gout, 
chronic  rheumatic  arthritis,  arthrite  seche,  osteoarthritis,  nodosity  of 
the  joints,  rheumatoid  arthritis,  nodular  rheumatism,  dry  arthritis,  pro- 
liferating arthritis,  malum  senile,  and  chronic  articular  rheumatism. 

The  name  arthritis  deformans,  proposed  by  Virchow,  is  used  here, 
as  it  is  descriptive  and  involves  no  etiological  theory  or  pathological 
basis. 

Definition. — Arthritis  deformans  is  a  chronic,  non-suppurative  affec- 
tion, which  attacks  the  joints,  crippling  and  deforming  them.  Although 
the  affection  is  a  chronic  one,  it  is  subject  to  acute  exacerbation.  The 
disease  is  common,  and  affects  not  only  man,  but  many  other  animals, 
such  as  horses,  cattle,  dogs  and  other  carnivora,  and  even  birds.  The 
affection  varies  in  its  manifestations,  as  may  be  inferred  from  the  vari- 
ous names  which  have  been  assigned  to  it.  Some  confusion  has  arisen 
in  the  minds  of  practitioners  from  the  terminology,  which  has  associ- 
ated the  affection  with  rheumatism,  the  disease  having  been  called 
chronic  rheumatism,  chronic  rheumatoid  arthritis,  etc.  The  affection 
is  one  of  a  distinct  type  with  variations,  and  is  characterized  by  stiff- 
ness, some  pain,  and  discomfort  of  the  affected  joint,  with  gradual 
progress  of  the  disease  and  subsequent  distortion  and  malformation  of 
the  joints. 

Pathology. — The  pathology  of  this  affection  has  been  the  subject  of 
much  discussion  and  is  not  yet  understood.  Some  writers  have  claimed 
that  it  is  of  infectious  origin,^  others  that  it  is  dependent  upon  changes 

'Schiiller:  Berl.  klin.  Woch.,  1893,  S65. — Dor:  Comptes  rend.  Soc.  de  Biol, 
1S93,  899.— Bloxail :  Lancet,  1S96,  i.,  1120. — Bannatyne,  VVohlmann,  and  Bloxall : 
Lancet,  April  25th,  1S96. — Teissier:  "  Du  Rhum.  goutteux."  Lyon  Med.,  1897, 
169. — Charrin  :  "La  rhum.  chron.  de  Tinfection."  Prog,  med.,  1894,  No.  43.— 
Pribram:  "  Chr.  Gelenkrheum.  und  Osteoarthritis  Deformans,"  Wien,  1902,  p.  95. 

196 


ARTHRITIS  DEFORMANS. 


197 


in  the  central  nervous  system,  and  others  that  it  is  due  to  the  presence 
of  some  toxin  as  yet  unknown.  In  the  opinion  of  several  observers  the 
disease  can  be  divided  into  two  or  more  distinct  affections.  Further 
investigation  is  needed  to  determine  these  questions.  The  pathological 
changes  are,  however,  characteristic  and  fairly  well  defined.  They  may 
be  said  to  consist  of  fibrous  degeneration  of  the  tissue  of  the  joints, 
with  resulting  changes  in  the  development  of  scar  tissues,  and  in  the 
more  adv^anced  cases  in  the  transformation  of  degenerative  fibrous  tis- 


FlG.  175.  — Arthritis  Deformans  of  Knee-joint. 

sues  into  abnormal  bony  growths.  The  process  may  at  any  stage  be- 
come arrested  and  stationary.  The  affection  begins  in  the  synovial 
membrane,  the  cartilage  being  attacked  either  at  the  same  time  or  but 
little  later.  The  synovial  membrane  and  capsule  are  congested,  swol- 
len, thickened,  and  in  parts  relaxed.  If  the  joint  is  opened,  in  addition 
to  the  congestion  of  the  synovial  membrane  one  finds  thickening  of  the 
villi  and  folds  of  the  membrane,  which  may  be  extensive,  so  that  an 
arthritis  villosa  may  be  said  to  exist.  In  some  instances  these  enlarge- 
ments may  take  on  cartilaginous  formation  and  even  ossification,  and. 


iqS 


ORTHOPEDIC  SURGERY. 


if  they  become  freed  from  their  attachments,  they  may  become  loose 
bodies  in  the  joint.  In  other  cases  the  enlargements  undergo  a  fatty 
degeneration,  so  that  they  have  been  regarded  as  fatty  tumors.  The 
term  lipoma  arborescens  is  applied  to  this  condition.' 

The  cartilage  of  the  joints  becomes  affected  in  spots  and  shows 


^^ 

Fig.  17D. — Vertical  Sec- 
tion through  Part  of  the 
Bodies  of  Sacral  Ver- 
tebrse  from  a  Case  of 
SpondylitisDeformans. 
Drawing  shows  the 
new  formation  of  dense 
bone  along  the  anterior 
surface  which  is  espe- 
cially marked  at  the 
intervertebral  discs. 
(By  the  courtesy-  of  the 
Department  of  Surgi- 
cal Pathology  of  the 
Harvard  Medical 
School.) 


Fig.    177.— Arthritis   Deformans    of    Hip. 
Museum.) 


(Warren 


fibrillary  thinning,  degeneration,  and  vascularization.  Pannus  may  de- 
velop, which  becomes  united  with  the  growth  from  the  synovial  mem- 
brane. In  some  cases  in  which  the  cartilage  is  covered  by  pannus 
there  follows  the  formation  of  cicatricial  tissue  and  iibrous  or  bony  an- 
kylosis, with  possible  subluxation  and  distortion  of  the  joints.  The 
'  Painter  and  Erving  :  Amer.  Jour,  of  Orth.  Sur.,  vol.  i.,  No.  2,  p.  109. 


AR  THE  I TIS  DEFORMANS. 


199 


cartilage  may  be  entirely  absorbed  and  bare  surfaces  of  bone  left, 
which  become  thickened.  In  other  places  there  may  be  areas  of  carti- 
laginous thickening  or  hypertrophy,  but  where  interarticular  pressure 
occurs  areas  of  absorption  of  cartilage  are  likely  to  be  found.  In  cer- 
tain cases  when  the  pressure  is  more  gradual  histological  changes  may 
take  place  in  the  cartilage  in  a  different  way.  The  osteoid  elements  in 
these  cases  apparently  invade  the  cartilage,  with  the  development  of 
bone  in  irregular  directions,  the  regions  of  the  exposed  bone  being 
filled  with  osteoid  elements,  so  that  a  layer  of  hard,  cicatricial  bone  is 
developed. 

In  the  viarroiv  various  changes  may  occur.     Fatty  and  mucoid  de- 


FlG.  178.— Bones  of  Hand  Badly  Deformed  by  Arthritis  Deformans.     (Warren  Museum.) 


generation  may  follow  the  destruction  of  the  cartilage,  giving  the  bone 
greater  translucency  to  ,t"-ray  illumination,  or  osteoid  cells  may  be  de- 
veloped and  abnormal  bone  be  found  in  regions  where  it  does  not  be- 
long. Irregular  formation  of  bone  may  also  take  place  in  the  perios- 
teum, the  fibrous  attachment  of  the  capsule,  the  ligaments,  and  the 
insertion  of  the  periarticular  muscles;  this  process  is  preceded  by 
fibrous  thickening.  The  absorption  of  the  parts  of  the  bone  spoken  of, 
with  the  changes  induced  by  the  irregular  pressure,  the  abnormal 
growth  of  exostoses,  and  the  consequent  changes  of  shape  complete  the 
distortion.  The  distortion  of  the  joint  is  also  the  result  not  only  of  the 
changes  in  the  shape  of  the  bones,  but  also  in  their  relation  to  each 


200 


ORTHOPEDIC  SURGERY. 


other.  It  is  due  partly  to  relaxation  of  the  capsule  in  places,  with  con- 
traction in  other  places,  and  to  pull  of  the  muscles  from  the  muscular 
spasm  reflex  to  joint  irritation.  The  immobility  of  the  joint,  its  altered 
function  and  the  consequent  development  of  new  bone,  and  the  inflam- 
matory or  irritative  changes  in  the  periarticular  tissues  and  in  the  peri- 
osteum, all  contribute  to  the  distortion  of  the  joint.  As  a  rule,  the  cap- 
sule and  capsular  ligaments  are  the  parts  chiefly  involved,  the  wearing 
away  of  the  cartilage  occurring  only  at  points  of  interarticular  pressure 

in  a  joint  restricted  in  motion.  In 
other  cases  the  changes  in  the 
shape  of  the  bones  by  the  develop- 
ment of  marginal  exostoses  are 
considerable.  In  other  cases  the 
synovial  changes  predominate, with 
the  development  of  villi  and  pos- 
sible pannus  and  cartilaginous  ab- 
sorption. In  lighter  cases  the 
changes  in  the  cartilage  are  limited 
to  a  diminution  in  its  normal  glis- 
tening appearance.  It  must  be 
remembered  that  tuberculous  de- 
generation of  chronically  enlarged 
synovial  villi  ma}'  occur,  but  it  is 
to  be  regarded  as  a  pathological 
process  distinct  from  arthritis  de- 
formans. 

The  muscles  controlling  the 
joint  become  changed  and  undergo 
atrophy  and  fibrous  degeneration, 
and  certain  muscles  may  become 
contracted,  while  others  are  over- 
stretched. The  periosteal  muscle 
attachments  are  thickened  and  are 
likely  to  become  the  seat  of  the  de- 
posit of  bone.  The  periarticular  subcutaneous  tissue  and  the  fascia  in  the 
vicinity  of  the  joint  are  likely  to  become  invoh^ed  in  the  process.  In 
this  case  they  are  found  to  be  cedematous,  and  swelling  followed  by  hy- 
perplasia and  permanent  thickening  occurs.  The  synovial  fluid  in  some 
instances,  especially  in  the  more  acute  stages,  is  increased  in  amount 
and  becomes  slightly  turbid.  Acute  enlargement  of  the  lymphatic 
nodes  and  the  spleen  is  not  often  seen  in  the  arthritis  deformans  of 
adults.  Still '  has,  however,  described  such  enlargement  in  a  separate 
form  of  the  disease  seen  in  children.  Such  changes  diminish  or  disap- 
'  Medico-Chir.  Trans.,  1S97. 


Fig.  179. — Spondj-lilis  Deformans  Showing 
Deposits  of  Bone  at  the  Sides  of  the  Verte- 
brae.    (Warren  Museum.) 


ARTHRITIS  DEFORMANS. 


201 


pear  as  the  patients  become  older.  The  blood  is  normal  in  most  cases, 
as  to  the  percentage  of  haemoglobin,  the  leucocyte  count,  and  the 
differential  count.  The  urine  shows  no  characteristic  changes.  Gold- 
thwait  has  found  an  increased  elimination  of  calcium  salts. 

Complications  are  not  uncommon  in  advanced  cases,  from  enlarge- 
ment of  the  heart,  chronic  nephritis,  and  the  various  manifestations  of 
arteriosclerosis. 

Etiology. — The  etiology  of  the  affection  is  not  yet  definitely  deter- 
mined.    In  certain  cases  injury  is  ascribed  as  the  exciting  cause,  but. 


Fig.  i8o.— Arthritis  Deformans  of  Hip-joint  Showing  Shortening  of  Neck  of  Femur.     Broad- 
ening of  head  and  broadening  and  loss  of  depth  in  acetabulum.     (Warren  Museum.) 


as  in  a  majority  of  cases  the  disease  develops  without  obvious  traumatic 
origin,  the  connection  between  the  injury  and  the  pathological  process 
is  not  evident.  Some  disturbance  of  metabolism  is  apparently  con- 
nected with  many  of  the  cases. 

Frequency  aiid  Ag-e.—The  affection  is  common  in  old  age,  as  may  be 
seen  from  the  following  figures,  taken  from  the  Long  Island  Pauper 
Institution  in  Boston.  Out  of  66  men  between  sixty  and  eighty  years 
of  age  12  showed  marked  manifestations  of  arthritis  deformans  to  a 
degree  which  interfered  with  locomotion  and  activity.  In  none  were 
Heberden's  nodes  observed.  In  the  women's  department  of  the  alms- 
house, of  96  patients  only  5  showed  affection  of  the  larger  joints,  while 


202 


ORTHOPEDIC  SURGERY. 


1 


r 


12  had  developed  Heberden's  nodes.  Out  of  26  cases  in  men,  the  dis- 
ease made  its  first  appearance  in  7  between  the  ages  of  fifty  and  fifty- 
nine,  and  in  46  women  in  10  between  forty  and  forty-nine. 

In  McCrae's  '  series  of  cases  the  age  of  onset  was  as  follows: 

i-io  years 15  cases  41-50  j-ears 28  cases 

11-20      " 30      "  51-60     "      iS 

21-30      "       33      "  61-70      "     6 

31-40      "       28      "  71-S0      "      2 

Localizatioji. — At  the  Long  Island  Hospital  the  joints  were  involved 

in  the  first  attack  in  the  following  order  of 
frequency,  according  to  statistics  prepared 
9               by  Dr.  F.  S.  Richardson: 
i  Wrist  and  hand 15 

:  Elbow I 

^                   Shoulder 10 

f                    Spine 2 

\                    Hip I 

\                  Knee 25 

Ankle  and  feet 6 

More  than  one  joint 4 

Unknown 10 

The  onset  was 

Acute,  obliging  the  patient  to  go  to  bed  for  a  few 

days  in 16 

Subacute  in 6 

Insidious  in 35 

Unknown  in 16 

Accordhig  to  Pribram,-  the  hand  was  ■ 
attacked  in  29  per  cent,  the  foot  in  24, 
the  knee  in  17.7,  the  shoulder  in  11,  the 
ankle  in  6,  the  elbow  in  3,  and  the  sterno- 
clavicle  articulum  in  i . 

Garrod  and  Bannatyne  give  the  order 
of  frequency  as  follows :  hand,  elbow,  cer- 
vical region,  knee,  ankle,  jaw,  shoulder, 
hip,  sterno-clavicular  joint. 

Symptoms.  —  Early  Syuiptouis.  —  The 
onset  of  the  affection  is,  as  a  rule, 
gradual,  and  no  characteristic  early  symp- 
toms are  noted.  In  a  large  majority  of 
cases  it  occurs  in  older  people,  and  females  are  more  often  affected. 
The  early  symptoms  are  most  often  a  gradually  increasing  lack  of 
flexibility   in    certain    joints,    which   is   followed   by   occasional    pain 

'  McCrae  :  Journ.  Am.  I\Ied  Assn..  October  Sth.  1904,  p.  1027. 
'  Alfred  Pribram  :  "  Chronischer  Gelenkrheumatismus  und  Osteoarthritis  De- 
formans," Wien,  1902. 


Fig.  iSi. — Ank^'losis  of  Knee-joint 
Following  Arthritis  Deformans, 
Showing  Osteophj'tes  and  Ossi- 
fication of  Ligaments.  (Warren 
Museum.) 


ARTHRITIS  DEFORMANS.  203 

after  unusual  exertion.  Cracking  of  the  joint  is  heard,  which  has 
been  studied  by  Blodgett  with  the  aid  of  a  stethoscope.  The  stiffness 
of  the  joint  when  overused  in  the  early  stages  is  most  evident  after  a 
period  of  rest.  In  this  early  stage  it  may  be  a  long  period  before  the 
disease  is  recognized,  and  the  symptoms  may  be  confused  by  a  numb- 
ness or  crackling  or  burning  sensation  in  the  joint,  sometimes  associ- 
ated with  vasomotor  disturbances  which  cause  redness  of  the  skin.  In 
a  certain  number  of  cases  during  this  early  stage,  before  the  marked 
appearance  of  characteristic  changes,  a  slight  elevation  of  temperature 
and  an  increase  of  pulse  may  be  observed,  which  may  persist  for  some 
time.  In  addition  to  the  general  discomfort,  there  may  be  also  present 
impairment  of  the  general  condition,  shown  by  loss  of  appetite  and 
wakefulness.  The  gradual  increase  of  the  symptoms  is  accentuated  at 
times  by  slight  acute  attacks,  induced  generally  by  accident  or  follovv- 


FlG.  182.  — Arthritis  Deformans  in  a  Child  of  Ten,  of  Lon^^  Duration.  Most  of  the  joints  af- 
fected. Showing'  enlargement  of  elbows,  wrists,  and  ankles,  and  flexion  deformity  of 
knees. 

ing  overuse.  Long  periods  of  remission  with  slight  improvement  or 
relative  quiescence  of  symptoms  often  occur,  but  on  the  whole  the  dis- 
ability increases. 

In  other  cases  the  invasion  is  somewhat  acute,  so  that  the  affection 
resembles  what  is  ordinarily  known  as  acute  rheumatism,  differing  from 
it,  however,  in  the  absence  of  profuse  perspiration  and  markedly  high 
temperature.  A  sensation  of  swelling  and  actual  swelling  of  the  joint, 
with  some  pain  on  movement,  with  perhaps  some  limitation  of  the  ex- 
tremes of  motion,  follow  the  changes  described. 

Sivclling. — The  swelling  varies  greatly  both  in  amount  and  in  its 
location.  In  the  milder  cases  of  the  most  chronic  type  at  an  early 
stage  little  or  no  swelling  is  present,  this  symptom  being  gradually  de- 
veloped later.  Swelling  of  the  synovial  tissues,  with  perhaps  synovial 
effusion,  is  likely  to  be  recognized  at  a  comparatively  early  stage  of  the 
affection,  and  is  of  importance.  Later  there  occurs  a  fusiform  swelling, 
consisting  of  oedematous  periarticular  tissues,  the  capsule,  and  the  liga- 
ments, along  with  some  inflammation  of  the  synovial  membrane. 

Stiffness. — The  limitation  of  motion  in  affected  joints  is  due  partly 


204 


ORTHOPEDIC  SURGERY. 


to  the  mechanical  obstructions  to  motion  produced  by  the  pathological 
process,  and  partly  to  muscular  spasm,  which,  however,  is  a  much  less 
prominent  factor  than  in  tuberculous  disease,  except  when  the  process 
has  become  extensive. 

Distortion. — This  swelling  may  diminish,  leaving  the  joint  distorted 
by  the  muscular  spasm,  the  cicatricial  contraction  of  some  structures, 
and  the  relaxation  of  others, 
along  with  the  periarticular 
thickening  of  the  periosteum 
and  other  tissues  which  have 
become  the  seat  of  bony  deposit. 
Distortion  of  position  is  usually 
manifest  in  the  flexion  of  the 


Fig.    183. —Hand  in    Arthritis  Defor- 
mans in  a  Child  Ten  Years  Old. 


Fig.  184.  — Arthritis  Deformans  in  a  Child 
Involving- nearl\'  all  the  Joints.  Compar- 
atively earl}^  Stage. 


joints,  but  in  the  hands  the  distortion  may  be  manifested  as  a  hyper- 
extension  of  the  fingers,  with  deviation  to  the  ulnar  side  in  connection 
with  the  distortion  and  alteration  in  the  shape  of  the  articular  ends  of 
the  bone. 

Skin  and  Fascia. — The  subcutaneous  tissue  and  the  fascia  undergo 
changes,  which  are  characterized  at  first  by  swelling,  which  is  followed 
by  thickening  and  contraction.     In  certain  places  in  the  fascia,  nodules 


ARTHRITIS  DEFORMANS. 


205 


may  be  felt,  which  may  be  the  occasion  of  great  discomfort  when  they 
occur  in  the  plantar  fascia,  which  is  occasionally  the  case.  Bands  of 
contracted  fascia  and  subcutaneous  thickening  in  the  hands  may  cause 
a  contraction  in  flexion  of  the  ulnar  fingers  described  by  Dupu}-tren. 

Varieties. — Several  varieties  of  this  affection  will  be  met,  which 
may  be  grouped  as  follows : 

I.  Several  joints  may  be  involved,  with  swelling  and  without  marked 
exostoses.  This  variety  attacks  all  ages,  but  is  more  frequently  seen 
in  the  middle-aged  or  young.     This  type  has  been  called  the  polyartir- 


FlG.  185. — Arthritis  Deformans  following  Gonorrhoea.  Considerable  boggy  swelling  of  and 
effusion  into  the  joints.  Ulnar  deviation  at  proximal  phalangeal  joints.  Painful  during 
active  stage  only.  (By  the  courtesy  of  the  Department  of  Surgical  Pathology  of  the  Har- 
vard ^ledical  School.) 

ular,  atrophic,  or  chronic  rheumatoid  type.     It  has  also  been  called 
nodular  arthritis  or  arthritis  nodosa. 

2.  A  monarticular  type,  attacking  chiefly  the  larger  joints,  may  oc- 
cur. In  this  form  exostoses  develop  and  the  joint  becomes  enlarged 
by  the  abnormal  development  of  bone.  The  process  is  of  slow  devel- 
opment and  is  seen  in  older  patients  or  in  patients  whose  tissues  may 
be  regarded  as  prematurely  s-enile.  This  group  is  called  the  monartic- 
ular, hypertrophic,  or  osteoarthritic  variety.  A  sharp  distinction  be- 
tween these  types  is  not  readily  made,  and  they  ma}'  be  regarded  as 
different  stages  of  the  same  process,  the  first  occurring  in  younger 
cases,  the  second  when  the  progress  is  slower  and  the  changes  are 
more  completely  developed. 

3.  A  third  type,  more  commonly  seen  in  women  and  children,  is 


206 


ORTHOPEDIC  SURGERY. 


characterized  by  a  stiffening  of  several  joints,  with  synovial  swelling 
and  a  late  development  of  changes  in  bone.  This  has  been  termed  the 
fibrinous  type,  arthrite  fibreuse  (arthritis  fibrosa),  and  ankylosing 
arthritis.  Goldthwait  has  described  this  as  an  infectious  type,'  but 
McCrae  ^  is  inclined  to  believe  that  it  is  not  improbable  that  all  forms 
may  be  regarded  as  infectious  or  the  result  of  a  toxin  as  yet  undiscov- 
ered.    For  that  reason  the  term  infectious  has  been  avoided  by  us. 

4.  A  fourth  type  of  the  affection  is  frequently  seen  in  elderly  wom- 
en, the  chief  characteristic  of  which  is  to  be  found  in   ''  Heberdeiis 


Fig.  186.— Hand  in  Arthritis  Deformans,  Sho-w- 
ing  the  Enlargement  at  the  Middle  of  the 
Middle  Finger.  (By  the  courtesy  of  the  De- 
partment of  Surgical  Pathology  of  the  Har- 
vard Medical  School.) 


Fig.  187.— Arthritis  Deformans  of  Long 
Standing  (Heberden's  Nodes).  Marked 
enlargement  of  the  distal  phalangeal 
joints.  (By  the  courtesy  of  the  Depart- 
ment of  Surgical  Pathology  of  the 
Harvard  Medical  School.) 


nodes P  This  term  is  applied  to  a  form  of  arthritis  deformans  attacking 
the  fingers  at  the  last  phalangeal  articulation.  Pathologically  the  process 
js  the  same  as  that  seen  in  other  articulations,  namely,  fibrous  changes 
in  the  synovial  tissues,  the  formation  of  pannus  and  absorption  of  the 
cartilage,  periosteal  thickening,  periarticular  swelling,  and  later  the 
irregular  formation  of  bone,  wdth  subluxation  and  displacement  and 
alteration  in  the  direction  of  the  bones  forming  the  joint. 

The  earlier  writers  classed  the  affection  as  a  form  of  gout,  but, 
although  similar  distortions  are  seen  in  gout,  characteristic  Heberden's 

'J.  E.  Goldthwait:  Bos.  Med.  and  Sur.  Jour..  Januan,-  2Sth.  1S9-.  and  1904. 
-McCrae:  Jour,  of  Amer.  I\Ied.  Association,  xliii  .  15,  pp.  1027-103S. 


ARTHRITIS  DEFORMANS. 


207 


nodes  do  not  have  chalkstone  deposits.  The  deformity  occurs  more 
commonly  in  women  than  in  men,  appearing  after  middle  life.  It  is 
usually  accompanied  by  similar  changes  in  other  joints,  but  it  may  be 
limited  to  the  finger-joints  alone.  The  fingers  are  not  very  painful, 
though  there  may  be  in  the  early  stages  slight  pain  and  a  prickling  and 
itching  sensation. 

The  treatment  of  these  joints  is  similar  to  that  of  the  treatment  of 
arthritis  deformans  in  other  joints,  and  is  both  constitutional  and  local. 
The  course  of  the  affection  is  usually  slow,  though  there  may  be 
long  periods  when  but  little  change  is  noticeable. 

Pathological  changes  similar  to  those  described  above  are  also  seen 
in  a  chronic  joint  affection  following  gonorrhoea,  and  also  after  the 

eruptive  diseases,  such  as  scarlet  fe- 
ver and  influenza.  These  manifesta- 
tions are  similar  to  milder  grades  of 
arthritis  deformans.     Whether  they 


Fig.  188.— Arthritis  Deformans  of  Long 
Standing  in  an  Old  Woman.  Disloca- 
tion of  the  proximal  phalangeal  joints. 
Ankylosis  of  middle  and  terminal  pha- 
langeal joints.  (By  the  courtesy  of 
the  Department  of  Surgical  Pathology 
of  the  Harvard  Medical  School.) 


i 

Fig.  189. — Double  Hallux  Valgus  and  Hammer 
Toes.    Associated  with  arthritis  deformans. 


should  be  classified  as  distinct  or  whether  they  are  the  exciting  cause 
of  a  chronic  process  which  may  end  in  arthritis  deformans  is  not  deter- 
mined. They  are  entirely  distinct  from  the  suppurative  affections  caused 
by  pyogenic  germ  infection,  and  are  perhaps  due  to  the  fact  that  a  pre- 
vious infection  has  weakened  the  patient,  rendering  him  subject  to  the 
influences  of  a  toxin  or  whatever  cause  develops  the  changes  seen  in 
arthritis  deformans. 

Diagnosis. — When  an  adult  is  affected  with  a  chronic  progressive 
affection  of  several  of  the  joints,  accompanied  by  swelling,  slight  pain, 
absence  of  suppuration,  and  with  an  increasing  deformity  and  an  en- 
largement, partly  of  bone  and  partly  of  the  capsule,  with  distortion,  a 


208  ORTHOPEDIC  SURGERY. 

diagnosis  of  arthritis  deformans  is  easily  made.  In  the  less  developed 
cases,  in  which  the  affection  is  monarticular  or  occurs  in  children,  it  is 
at  times  difficult  if  not  impossible,  without  a  careful  observation  of  the 
case,  to  determine  whether  the  case  is  tuberculous  or  not.  A  diagnosis 
can  be  made  by  incision  of  the  joint  and  inoculation  experiments.  In 
children  as  well  as  in  adults  chronic  non-suppurative  polyarticular  affec- 
tions are  more  probably  non-tuberculous. 

A  diagnosis  is  aided  by  an  A'-ray  examination,  which  in  advanced  tu- 
berculous affections  shows  marked  focal  destruction. 

In  arthritis  deformans  the  bone  may  be  either  thickened  or  show 
irregular  osteophytes  if  the  process  is  of  the  eburnating  type,  or  there 
may  be  an  increased  translucency  if  the  cellular  change  has  not  ad- 
vanced to  bone  formation. 

Treatment. — The  literature  of  the  treatment  of  this  affection  has 
been  extremely  unsatisfactory  until  recently.  The  administration  of 
iodide  of  potash,  iron,  cod-liver  oil,  and  antacid  and  antirheumatic  drugs 
was  formerly  recommended  as  a  routine  treatment.  Of  late  the  use- 
lessness  of  such  medicinal  treatment  has  been  generally  recognized, 
and  more  rational  methods  have  taken  its  place.  It  goes  without  say- 
ing that  an  early  diagnosis  is  of  importance  in  order  that  the  patient 
may  be  placed  under  proper  conditions  before  the  disease  has  made 
great  progress.  The  treatment  should  be  both  constitutional  and  local. 
Among  the  constitutional  measures  one  of  the  most  important  is  diet. 

Diet. — It  was  formerly  supposed  that  the  affection  was  of  a  gouty 
nature,  and  that  a  meat  diet,  and  especially  one  including  red  meat, 
was  to  be  prohibited.  This  was  based  upon  the  theory  that  the  affec- 
tion was  of  a  rheumatic  character  and  due  to  an  excess  of  uric  acid. 
The  theory  having  been  disproved,  it  is  now  believed  that  the  affection 
is  either  caused  or  influenced  by  malnutrition,  and  for  that  reason  a  re- 
stricted diet  is  to  be  avoided.  If  meat  is  well  digested  and  is  satisfac- 
tory to  the  patient,  it  is  manifestly  better  that  the  patient  should  not 
be  deprived  of  it.  The  diet  should  be  carefully  looked  after  in  each 
case  and  should  be  directed  according  to  the  individual  digestion  of  the 
patient.  The  patient  should  avoid  an  excess  of  every  variety  of  food. 
A  starchy  diet  or  a  diet  containing  a  great  deal  of  sugar  should  be 
avoided  in  case  any  intestinal  disturbance  follows.  It  should  be  remem- 
*bered  that  it  is  not  only  the  stomachic  but  also  the  intestinal  digestion 
which  must  be  watched.  As  the  affection  is  influenced  by  the  impair- 
ment of  the  general  metabolism,  indigestion  should  be  carefully  avoided. 
A  glass  of  one  of  the  laxative  mineral  waters  before  breakfast  is  desir- 
able where  there  is  any  tendency  to  constipation. 

Clothing. — The  clothing  of  such  patients  should  be  regulated  in 
such  a  way  as  to  furnish  a  greater  protection  from  sudden  changes  in 
temperature  and  to  allow  absorption  without  too  rapid  evaporation  of 


ARTHRITIS  DEFORMANS.  209 

perspiration.  This  object  is  best  reached  by  the  use  of  woollen  under- 
garments. 

General  Routine. — It  is  hardly  necesary  to  add  that,  so  far  as  the 
general  conditions  go,  a  regular  life  under  the  most  favorable  surround- 
ings possible  is  to  be  aimed  at,  that  extreme  fatigue  or  mental  strain  is 
to  be  avoided  so  far  as  practicable,  and  that  so  far  as  possible  the  unfa- 
vorable surroundings  and  conditions  are  to  be  eliminated.  The  rest  of 
the  general  treatment  consists  in  properly  regulating  the  diet,  in  pro- 
moting elimination  by  the  skin,  kidneys,  and  intestines,  and  by  the  use 
of  tonics  when  rec|uired. 

Exercise. — It  is  particularly  important  that  all  means  of  elimination 
of  waste  products  should  be  encouraged.  It  is  for  this  reason  neces- 
sary not  only  that  the  intestines  should  be  normally  active,  but  it  is  also 
desirable  that  both  the  perspiration  and  kidneys  should  have  an  oppor- 
tunity for  free  action.  As  the  latter  are  influenced  by  increase  of 
fluid  in  the  patient's  diet,  it  is  to  be  carefully  prescribed.  Exercise 
promoting  a  free  perspiration  is  also  desirable.  This  in  weaker  patients 
can  be  done  by  the  judicious  use  of  hot  baths  and  hydrotherapeutics, 
but,  where  exercise  is  possible,  perspiration  which  results  from  muscu- 
lar effort  is  more  beneficial. 

Drugs. — General  tonics  should  be  given,  in  the  shape  of  strychnine 
if  a  nerve  tonic  is  desired,  and  in  case  on  blood  examination  it  is  found 
that  an  anaemia  exists,  iron  is  indicated.  Aspirin  has  some  effect  at 
times  in  relieving  pain. 

Local  Treatment. 

The  object  of  local  treatment  is  to  promote  the  circulation  and  to 
stimulate  the  tissues  around  the  joints  which  are  undergoing  a  proc- 
ess of  change,  which  must  be  regarded  as  a  degeneration  rather  than 
an  inflammation. 

Rest. — When  the  joints  are  strained  and  congested,  protection  from 
strain  is  desirable,  but  absolute  rest  and  fixation  are  to  be  avoided  ex- 
cept temporarily  during  the  existence  of  acute  pain.  Even  at  this  stage 
the  joints  should  be  rested  rather  than  fixed. 

Treatment  by  Rest. — When  the  joints  are  in  an  irritated  condition, 
as  indicated  by  pain,  tenderness,  or  discomfort  during  and  after  motion, 
restriction  of  use  is  for  a  time  advisable.  This  can  be  furnished  by  one 
of  the  mechanical  appliances  described  for  preventing  joint  motion  in 
tuberculous  diseases  of  the  joints  or  by  the  application  of  a  removable 
plaster  support.  Such  restriction  of  joint  motion  is  to  be  employed  for 
as  short  a  time  as  possible  and  to  be  discontinued  as  soon  as  the  acute 
stage  is  past.  Motion  is  to  be  regarded  as  a  normal  function  of  the 
joint,  and  degenerative  changes  take  place  more  cjuickly  in  unused 
14 


2.1  o  ORTHOPEDIC  SURGERY. 

joints,  and  hence  in  this  condition,  prolonged  fixation  is  to  be  avoided  as 
probably  detrimental. 

Exeixiscs. — The  principle  of  treatment  is  that  the  joints  should  be 
used  within  the  arc  of  their  possible  motion  freely,  but  that  strain,  vio- 
lence, and  excessive  use  should  be  avoided.  As  far  as  possible  the  arc 
of  motion  should  be  increased,  but  this  should  not  be  done  at  the  ex- 
pense of  irritating  the  joint.  Exercises  for  the  purpose  just  described 
can  be  given  in  the  form  of  passive  manual  manipulation  or  by  the  aid 
of  such  mechanical  appliances  as  have  been  devised  for  the  purpose  of 
moving  the  joint  without  the  use  of  the  muscles.  These  should  not  be 
pushed  to  the  point  of  causing  much  pain.  Various  forms  of  pendulum 
exercises  can  be  employed  and  the  well-known  Zander  appliances  are  to 
be  used,  but,  being  complicated  and  expensive,  they  are  beyond  the 
reach  of  general  practitioners.  Simple  apparatus  can  be  devised  which 
will  answer  this  same  purpose.  As  the  joints  improve,  carefully  pre- 
scribed active  exercises  can  be  added  to  and  take  the  place  of  the  pas- 
sive exercises.  Exercises,  either  active  or  passive,  given  for  this 
purpose,  are  best  done  when  the  body  weight  is  removed  from  the 
joint. 

Hot  Ail'.  Local. — The  local  application  of  dry,  hot  air,  carried  to  a 
point  of  from  300°  to  400°  F.,  has  proved  to  be  of  benefit  in  the  treat- 
ment of  arthritis  deformans  in  many  instances,  especially  in  the  lighter 
cases.  The  limb  should  be  placed  in  a  properly  constructed  oven, 
wrapped  in  flannel,  and  the  heat  raised  to  the  highest  comfortable 
point.  This  treatment  should  continue  from  twenty  minutes  to  an 
hour.  The  treatment,  although  often  productive  of  great  benefit, 
should  be  applied  with  discretion  and  the  patient  watched,  as  it  is  at 
times  exhausting  and  may  irritate  the  joint.  In  the  stage  of  acute 
inflammation  it  is  not  so  beneficial  as  at  other  times.  The  heating  of 
the  joint  should  be  followed  by  rest,  and,  in  cases  that  are  not  acute, 
massage  following  the  heating  may  be  of  use. 

Hot  Aii\  General. — Hot-air  baths  for  the  whole  body  may  be 
given  by  means  of  a  metal  cylinder  lined  with  asbestos,  which  is 
long  enough  to  include  the  body  up  to  the  armpits  and  is  heated  by 
gas,  gasoline,  or  electricity.  The  patient  lies  in  the  cylinder  and  the 
temperature  is  raised  to  350°  or  400°.  The  heat  should  be  run  up  rap- 
idl}^  in  order  to  secure  the  necessary  degree  of  physiological  effect  as 
quickly  as  possible.  The  pulse  and  temperature  rise,  and  an  exposure 
to  this  heat  from  twenty  to  twenty-five  minutes  is  sufficient.  The 
method  is  described  as  being  of  greater  use  than  the  local  application, 
and  is  suited  to  the  treatment  of  the  severer  cases. 

Electric  Light  Bat  lis. — The  use  of  the  combined  heat  and  light 
given  off  by  a  number  of  incandescent  electric  light  bulbs,  placed  inside 
of  a  box  similar  to  the  ordinary  cabinet  bath,  has  been  found  of  use.     It 


ARTHRITIS  DEFORMANS.  211 

is  said  that  free  perspiration  is  induced  at  a  lower  temperature  than 
when  the  heat  alone  is  used  without  the  light. 

Massage. — Manual  massage  is  of  assistance  in  stimulating  the  local 
circulation  and  promoting  the  absorption  of  some  of  the  swelling.  It  is 
a  remedy  often  of  use,  but  sometimes  exaggerates  the  symptoms.  It 
should  be  used  with  great  gentleness,  and  the  joint,  if  acutely  irritated, 
should  be  very  lightly  rubbed,  the  attention  being  directed  to  the  tis- 
sues about  the  joint.  As  the  tolerance  of  the  joint  increases  it  may 
receive  more  massage,  but  many  cases  are  rendered  more  acute  and 
painful  by  the  use  of  massage  applied  for  too  long  a  time.  It  is  useful 
only  in  so  far  as  it  is  quieting  to  symptoms,  and  should  be  done  with 
gentle  passive  movements.  Mechanical  vibratory  stimulation  is  of  use 
in  connection  with,  or  replacing  massage.  It  may  be  given  as  a  general 
treatment  for  purposes  of  stimulation,  and  locally  it  serves  as  a  sedative 
to  muscular  irritability. 

Electricity . — Electricity  may  be  of  use  in  the  form  of  galvanism  ap- 
plied once  or  twice  weekly,  or  of  static  electrical  application  made  more 
often.  The  Morton  wave  current  and  some  of  the  high-frequenc)''  cur- 
rents applied  either  locally  or  generally  may  be  of  use  with  these  or 
may  replace  them.' 

HydrotJierapy .—T\\Q.  use  of  hydrotherapy  in  this  disease  is  at  times 
of  undoubted  benefit.  The  combination  of  a  change  in  surroundings, 
careful  diet,  and  massage,  in  connection  with  the  water  treatment,  fre- 
quently unite  in  improving  the  patient's  general  and  local  condition. 
The  use  of  warm  alkaline  baths  may  be  varied  by  the  use  of  baths  of 
hot  mud,  a  mode  of  treatment  for  which  special  arrangements  are  nec- 
essary. The  subject  of  hydrotherapy  is  too  extensive  to  be  entered 
upon  here,^  and  in  the  treatment  of  arthritis  deformans  it  is  to  be  re- 
garded as  a  measure  for  both  general  and  local  treatment,  at  times  of 
much  value.  The  recent  establishment  of  hydrotherapeutic  institutions 
in  the  larger  cities  serves  to  make  this  treatment  more  available.^ 

Treatment  by  the  Application  of  Hot  Sand. — Burying  the  affected 
joint  in  hot  sand  is  a  method  of  applying  dry  heat.  The  heat  cannot 
be  as  well  regulated  as  the  hot-air  treatment,  but  it  will  be  found  to  be 
efficacious. 

Vacuum  Tiratmeut. — Placing  the  joint  within  a  glass  case  and  ex- 
hausting the  air  by  means  of  a  pump  has  been  tried  with  benefit  in  sev- 
eral  cases.     It  is  a  means  of  causing  passive  hyperaemia. 

Treatment  by  Passive  Congestion. — Bier  has  recommended  a  method 
of  treating  arthritis  deformans  which  is  specially  applicable  for  the  knee 
and  wrist.     This  consists  of  setting  up  a  local  passive  congestion,  which 

'  Skinner:  Jour.  Amer.  Tvled.  Assn.,  October  Sth,  1904. 
-  Baruch  :  "  Hydrotherapy,"  New  York,  1S99. 
•'Pratt:  Boston  Medical  and  Surg.  Journ.,  1904. 


2  12  ORTHOPEDIC  SURGERY. 

can  be  accomplished  by  applying  a  bandage  from  the  foot  up  to  the 
knee,  leaving  the  knee  uncovered  and  applying  an  elastic  bandage  di- 
rectly above  the  knee,  sufficiently  tight  to  cause  a  congestion  of  the 
joint.  This  congestion  should  not  be  so  great  as  to  give  rise  to  a  cold 
condition  of  the  surface.  The  tissues  should  become  blue  and  the  pa- 
tient should  suffer  some  discomfort,  but  pain  should  not  be  experienced. 
This  congestion  should  be  allowed  to  continue  for  from  seven  minutes 
to  half  an  hour,  and  massage  should  be  applied  to  the  joints  afterward. 
The  method  is  of  advantage,  but  does  not  take  the  place  of  dry  heat, 
though  it  may  be  used  in  certain  cases  in  which  dry  heat  is  not  applica- 
ble.^ 

Operative  Treatment. 

As  functional  use  of  a  joint  affected  with  deformity  is  essential  to 
recovery,  when  deformities  exist  in  the  lower  extremity  one  of  two 
things  is  necessary.  Either  the  limb  must  be  straightened  b}'  appara- 
tus or  by  operative  means,  unless  gymnastic  exercises  and  stretching 
can  be  used  for  the  purpose. 

Medianical  Correction  of  Deformities.— ^\vq.  same  methods  that  are 
used  in  the  correction  of  deformities  of  tuberculous  disease  can  also  be 
applied  to  the  deformities  following  arthritis  deformans,  with  the  excep- 
tion that  the  latter  occurs  more  commonly  in  adults  than  in  children 
and  greater  difficulty  is  met  in  correcting  these  deformities  without  an 
anaesthetic.  On  the  other  hand,  greater  force  can  be  used  without 
danger  of  suppuration  in  arthritis  deformans  than  is  possible  in  the 
tuberculous  affections. 

Removal  oj  Obstructions. — The  operation  consists  of  forcible  correc- 
tion with  or  without  tenotomy,  after  the  removal  of  any  obstructive 
fringes  or  lipomata  if  such  interfere  with  the  motion  of  the  joint,  or  the 
removal  of  exostoses  if  these  act  as  obstructions.  It  is  manifest  that 
when  many  joints  are  involved  operative  interference  is  to  be  limited 
to  the  most  important  joints  or  the  joints  most  important  for  loco- 
motion. 

Goldthwaite  and  Painter  have  demonstrated  by  their  work  the  feasi- 
bility of  opening  the  knee-joint  and  removing  obstructing  fringes,  and 
it  is  manifest  that  where  an  exostosis  prevents  motion,  and  its  removal 
will  improve  the  function  of  the  joint,  it  is  desirable  that  it  should  be 
done.  It  should,  however,  be  remembered  that  in  many  of  these  the 
affection  is  not  simply  limited  to  an  alteration  in  the  synovial  mem- 
brane. 

Summary. — The  less  severe  cases  are  likely  to  be  relieved  by  being 
put  upon  a  proper  regimen  in  the  matter  of  diet,  exercise,  sleep,  baths, 

'A.  H.  Freiberg:  Amer.  Jour,  of  Orth.  Sur. .  vol.  ii..  Xo.  i.  p.  qo. 


ARTHRITIS  DEFORMANS.  213 

etc.  In  addition  to  this,  electricity,  massage,  douches,  hot-air  baths, 
and  the  other  methods  intended  to  improve  the  local  circulation  are 
likely  to  be  highly  beneficial. 

The  severer  cases  demand  more  careful  treatment  and  supervision, 
and  the  following  will  serve  as  the  type  of  a  desirable  routine:  The 
diet  should  be  generous.  The  patient  should  rest  in  bed  ten  out  of  the 
twenty-four  hours.  Tonics  and  mineral  waters  are  used.  Hot-air  or 
electric-light  baths  to  the  whole  body  are  given  two  or  three  times 
weekly.  Electricity  or  vibratory  stimulation  is  given  practically  daily. 
Passive  movements  are  given  to  the  affected  joints  with  a  view  to  in- 
creasing their  range  of  motion. 

The  treatment  of  arthritis  deformans  in  its  various  stages  requires 
not  only  patience  on  the  part  of  the  surgeon,  but  much  care  on  the 
part  of  the  patient.  Relief  can  be  offered  in  almost  all  instances,  and  a 
stay  of  symptoms  may  be  expected  to  follow  in  a  certain  number  of 
favorable  cases.  It  is  to  be  remembered  that  the  affection  is  essentially 
chronic  and  that  the  natural  course  of  the  disease  is  interrupted  by  as 
yet  unexplained  periods  of  remission.  It  is,  therefore,  difficult  to  ex- 
amine critically  the  principles  of  treatment  or  the  results  in  any  indi- 
vidual case,  but  it  is  certain  that  attention  to  the  patient's  general  con- 
dition, followed  by  the  improvement  which  is  brought  about  by  such 
measures  as  are  influential  in  improving  the  circulation,  makes  the  use 
of  the  limbs  possible  with  less  discomfort ;  the  correction  of  deformity, 
the  protection  of  the  limb  from  strain,  and  the  placing  of  the  limb  in 
such  a  position,  by  operation  or  by  apparatus,  that  locomotion  is  not 
accompanied  by  discomfort,  unite  in  aiding  the  joint  to  recover  its 
usefulness. 

Arthritis  Deformans  in  Children. 

In  children  the  characteristics  of  the  disease  do  not  vary  essentially 
from  those  in  adults.  Clinically  one  finds  the  same  type  of  manifesta- 
tions seen  in  adults  in  some  cases,  while  others  show  a  type  chiefly 
found  in  young  children,  which  was  described  among  others  by  Still 
and  is  sometimes  spoken  of  as  Still's  disease.'  In  such  cases  the  symp- 
toms begin  generally  before  the  second  dentition,  the  earliest  onset 
reported  being  in  a  child  fifteen  months  old.  In  this  type  the  cartilagin- 
ous and  bony  changes  are  slight,  and  progressive  and  deforming  swell- 
ing with  thickening  of  the  joint  and  periarticular  structures  takes 
place.  The  affection  is  polyarticular ;  pain  is  not  a  predominant  symp- 
tom, but  glandular  and  splenic  enlargement  is  common.  Recovery  may 
occur  in  these  cases.     The  treatment  does  not  vary  from  that  in  adults. 

'Still:  Med.-Chir.  Trans.,  1S97.— Spitzy :  Zeit.  f.  Orth.  Chir..  xl  .  4.  699  (with 
bibliography). — Goldthwaite :  "Infectious  Arthritis."  Boston  Med.  and  Surg. 
Journ.,  1904. 


214  ORTHOPEDIC  SURGERY. 

SPINE. 

Spondylitis  Deformans. 

Osteoarthritis  of  the  spine/  ankylosing  inflammation  of  the  spine/ 
rigidity  of  the  spine,  spondylose  rhizomelique/  neuropathic  curvature 
of  the  spinal  column/  kyphose  heredo-traumatique,  Bechterew's  dis- 
ease of  the  spine/  Steifigkeit  der  Wirbelsaule,  etc.,  are  names  which 
have  been  applied  to  the  condition. 

The  essential  character  of  this  affection  is  a  chronic  and  progressive 
stiffening  of  the  spine,  accompanied  by  pain. 

Pathology  and  Etiology. — -When  the  process  involves  the  spine  the 
same  differences  in  types  may  be  seen  as  those  described.  The  affec- 
tion may  be  characterized  by  stiffness  without  much  bony  change, 
or  the  bony  change  may  be  marked  and  the  deformity  distressingly  no- 
ticeable. When  the  spine  is  completely  stiffened  it  is  accompanied 
usually  by  some  loss  of  motion  in  the  articulations  of  the  rib,  corre- 
sponding to  the  fibrinous  arthritis  or  ankylosing  arthritis  seen  in  other 
joints. 

The  pathological  process  found  is  that  of  arthritis  deformans  modi- 
fied by  the  peculiar  structure  of  the  vertebral  column.  The  ligaments 
and  interarticular  cartilages  degenerate,  and  the  former  become  the 
seat  of  bony  deposits,  while  the  latter  may  hypertrophy  at  the  edges 
and  these  marginal  hypertrophies  become  ossified,  forming  a  lipped 
edge  to  the  vertebra.  The  interarticular  cartilages  degenerate  and  the 
vertebrae  become  fused  together.  A  deposit  of  new-formed  bone  occurs 
along  the  front  and  sides  of  the  column,  binding  the  various  vertebrae 
together. 

In  other  cases  the  hypertrophic  element  is  wanting  and  fusion  of 
the  vertebrae  occurs  by  disappearance  of  the  intervertebral  discs  without 
marked  deposit  of  new  bone. 

The  hips  and  shoulders  are  involved  in  the  process  in  a  certain 
proportion  of  cases,  showing  the  changes  characteristic  of  arthritis  de- 
formans. The  peripheral  joints  may  or  may  not  be  simultaneously 
affected. 

The  etiology  is  not  different  from  that  of  arthritis  deformans  else- 

'  Goldthwaite  :  Bost.  Med.  and  Surg.  Journ.,  1902,  p.  299. 

-Striimpell:  Deut.  Zeit.  f.  Nervenheilkde.,  1897,  338. 

^  Marie  :  Revue  de  Med.,  1898,  xviii.,  285. — VoUheim  :  Inaug.  Dissertation, 
Jena,  1902. — Siven:  Zeit.  f.  klin.  Med.,  xlix. — Rurah :  Am.  Journ.  Med.  Sci., 
November,  1903  (with  bibliography). — Simmonds  :  Fortsch.  a.  d.  Gebiete  d.  Roent- 
genstr. ,  vii.,  2. — Brodnitz  :  Zeitsch.  f.  orth.  Chir.,  xii.,  142.  —  Pribram:  "  Chr. 
Gelenkrheumatismus,"  etc.  ,Wien,  1902,  p.   158  (with  bibliography). 

■'Neurol.  Centralbl.,  1899,  vii.,  294. 

5  Neurol.  Centralbl.,  1893,  426;  Deutsch.  Zeit.  f.  Unfhkde.,  1S97,  xi. ,  326. 


ARTHRITIS  DEFORMANS. 


215 


where,  except  that  gonorrhoea  seems  to  be  quite  frequently  an  antece- 
dent of  the  affection.' 

There  has  been  a  tendency  to  recognize  two  types  of  the  affection : 


Flexion  Forward. 
II 


Flexion  to  Left. 
Ill 


IV  II 

Flexion  to  Rigfht.  Best  Standing  Position. 

Fig.  igo. — Arthritis  Deformans.     Involving  spine  from  upper  dorsal  to  mid-lumbar  region 

(J.  E.  Goldthwaite.) 

(i)  described  as  the  Bechterew  type,'  in  which  the  other  joints  are  gen- 
erally not  affected,  and  in  which  a  neuropathic  origin  has  been  assumed 

'  Bradford  :  Ann.  of  Anat.  and  Surg.,  1883,  vii.,  6. 

-  Striimpell  :   Deutsch.  Zeit.  f.  Nervenheilkunde,  1897,  iv. 


2  l6 


ORTHOPEDIC  SURGERY. 


to  exist;  (2)  the  Striimpell-Marie  type/  with  involvement  of  shoulders 
or  hips,  and  in  this  type  the  pathological  basis  is  found  in  an  ankylosis 
of  vertebrae  and  an  ossification  of  ligaments. 

Later  consideration  of  the  subject  has  tended  to  the  opinion  that 
the  two  types  are  not  distinct,  but  simply  the  natural  variations  of  a 

process  which  is  characterized 
in  general  by  marked  differ- 
ences in  its  manifestations. 

Symptoms. — Stiffness  and 
pain  in  the  spine  are  the  char- 
acteristic symptoms.  Stiff- 
ness at  first  is  partly  due  to 
muscular  irritability,  but  later 
may  become  the  result  of  an- 
kylosis. 

Motion  is  generally  re- 
stricted in  all  directions,  but 
bending  to  one  side  is  freer 
than  to  the  other  at  first. 
Lateral  deviation  of  the  spine 
is  likely  to  be  present.  The 
physiological  dorsal  curve  may 
be  increased  and  the  lumbar 
curve  generally  obliterated, 
after  a  while  the  whole  spine 
forming  a  bow  backward.  The 
gait  is  careful  and  simulates 
that  of  Pott's  disease. 

Pain  is  present  chiefly  in 
the  spine,  but  also  in  the  per- 
ipheral ends  of  the  nerves,  as 
in  Pott's  disease.  It  is  gener- 
ally more  marked  on  one  side 
than  on  the  other.  It  may  be 
a  subordinate  symptom  or  it 
may  be  so  acute  as  to  be  ag- 
gravated by  every  jar,  and  it 
may  be  paroxysmal.  Pains  of  a  neuralgic  character,  areas  of  disturbed 
sensation,  and  even  paralysis  may  be  present  in  the  legs  and  arms. 
These  are  due  to  the  compression  of  the  nerve  roots. 

The  patient  walks  more  or  less  bent  over  by  the  dorsal  kyphosis, 
and  in  stooping  the  motion  is  entirely  from  the  hips.     In  lying  down 
the  curves  are  not  affected  or  obliterated  in  the  later  stages.     The  lower 
'  Bechterew:  Deutsch.  Zeit.  f.  Nervenheilkunde,  1S99,  xv. 


Fig.  191.— Arthritis  Deformans  Following  Gonor- 
rhoea Involving  Spine  and  Many  Other  Joints. 
Spine  perfectly  rigid  except  upper  cervical  re- 
gion. (By  the  courtesy  of  the  Department  of 
Surgical  Pathology  of  the  Harvard  Medical 
School.) 


ARTHRITIS  DEFORMANS.  217 

spine  is  generally  first  affected  and  the  cervical  last.  In  the  severest 
cases  the  spine  is  stiff  from  the  sacrum  to  the  occiput,  and  permits  no 
more  motion  than  would  an  iron  rod.  In  the  severer  cases  the  ribs  are 
ankylosed  at  their  junction  with  the  spine,  and  the  chest  wall  scarcely 
mo\'es  in  inspiration,  or  it  may  be  entirely  stationary  and  the  breathing' 
is  wholly  abdominal.  As  the  cervical  vertebrae  are  usually  the  last  to 
be  affected,  motion  of  the  head  may  be  possible  after  the  dorsal  and 
lumbar  regions  have  become  rigid.  In  less  severe  cases  the  spine  is  not 
involved  to  the  whole  extent,  but  marked  stiffness  without  angular  pro- 
jection exists  in  a  portion  of  the  column.  Stiffening  and  flexion  of  the 
hips  is  present  in  some  of  the  cases,  and  leads  to  a  most  distressing 
gait  in  which  the  whole  body  is  carried  bent  forward. 

The  course  of  the  disease  is  chronic  in  the  extreme,  and  its  duration 
covers  many  years.  The  bone  inflammation  has  no  destructive  ten- 
denc}'  and  accomplishes  nothing  more  than  stiffening  the  vertebral  col- 
umn. The  impairment  of  the  general  health  consequent  upon  this  is 
generally  not  so  severe  as  one  would  anticipate. 

The  diagnosis  of  the  affection  can  be  made  by  recognizing  the  ri- 
gidity of  the  entire  vertebral  column  without  the  angular  prominence  of 
Pott's  disease,  nor  does  the  latter  affection  so  stiffen  the  whole  column, 
but  only  the  diseased  region.  Pott's  disease  involving  the  whole  or  a 
large  portion  of  the  vertebral  column  wTjuld  soon  lead  to  very  marked 
results  in  its  destructive  tendency.  The  immobility  of  the  ribs  is  a 
pathognomonic  sign  of  the  affection,  and  the  involvement  of  other 
joints  would  merely  confirm  one's  opinion  of  the  character  of  the  dis- 
ease. 

Prognosis. — It  need  hardly  be  said  that  the  prognosis  is  unfavorable 
as  to  complete  recovery.  Early  cases  may  pass  into  a  quiescent  stage 
by  means  of  proper  treatment  and  the  pain  subsides.  Most  cases  are 
improved  by  support  and  fixation.  If  the  other  joints  are  involved,  the 
patient's  condition  is  deplorable. 

Treatment. — The  general  measures  likely  to  be  of  use  have  been 
described.  In  the  acute  stage  the  use  of  fixation  is  indicated.  A  plas- 
ter or  leather  jacket  applied  without  suspension  is  the  best  means  of 
obtaining  this.  As  the  acute  symptoms  quiet  down,  massage  is  of 
value.  The  spine  should  be  protected  by  a  brace  so  long  as  it  is  pain- 
ful and  irritable.  The  use  of  manipulation  to  ward  off  the  approaching 
ankylosis  is  harmful  and  undesirable  at  all  stages  of  the  affection. 

HIP. 

Arthritis  deformans  of  the  hip-joint  is  an  affection  which  is  not  un- 
common in  patients  above  the  age  of  forty-five.  It  may  occur  as  a 
monarticular  affection  or  in  connection  with  a  simultaneous  affection 
of  some  of  the  other  joints. 


2i8  ORTHOPEDIC  SURGERY. 

Pathology  and  Etiology. — When  affecting  the  hip  it  is  known  as 
senile  coxitis,  malum  coxae  senile,  etc.  It  begins  in  many  cases  insidi- 
ously, while  in  others,  and  especially  monarticular  cases,  it  follows  after 
a  fall  upon  the  trochanter.  From  the  shortening  of  the  head  and  neck 
in  these  cases  it  was  long  supposed  to  be  an  impacted  fracture  of  the 
neck  of  the  femur,  but  the  shortening  results  from  the  absorption  of 
the  head  and  is  in  every  way  like  the  pathological  changes  found  in  the 
insidious  cases.     The  affection  may  occur  in  adolescents  and  children.' 

Symptoms. — The  affection  begins  with  pain  in  and  about  the  joint, 
often  shooting  down  the  course  of  the  sciatic  nerve  at  the  back  of  the 
leg  instead  of  down  the  front,  as  in  epiphyseal  ostitis.  At  this  stage 
the  affection  very  closely  simulates  sciatic  neuralgia.  Movements  of 
the  joint  beyond  a  certain  arc  are  painful,  and  a  noticeable  limp  is  pres- 
ent. External  rotation  and  hyperextension  are  particularly  painful 
movements  to  the  patient,  and  if  the  leg  is  manipulated  a  distinct  creak- 
ing is  sometimes  felt  which  is  most  noticeable  when  the  movements  are 
most  painful. 

Muscular  atrophy  of  the  limb  comes  on  and  the  nates  of  the  affected 
side  are  flaccid  and  flattened,  and  apparent  shortening  from  flexion  and 
adduction  is  present  in  the  diseased  limb,  as  well  as  true  bone  shorten- 
ing. Muscular  fixation  is  at  first  not  a  prominent  symptom,  except  in 
very  sensitive  conditions  of  the  joint,  but  the  arc  of  motion  gradually 
diminishes,  until  finally  the  joint  may  become  entirely  stiff  in  perhaps 
a  normal  position,  or  perhaps  adducted  or  flexed.  In  the  earlier  stages 
abduction  and  apparent  lengthening  of  the  limb  may  be  present  as  in 
hip  disease. 

The  position  which  the  limb  assumes  in  the  more  advanced  cases  of 
the  disease  is  one  which  is  calculated  to  be  most  misleading,  especially 
when  the  affection  has  followed  a  fall  upon  the  trochanter.  The  limb 
may  be  rotated  outward  and,  with  the  apparent  shortening,  presents  al- 
most a  complete  picture  of  an  impacted  fracture  of  the  neck  of  the  femur. 
In  other  instances  the  thigh  may  be  flexed  and  adducted  as  in  hip  dis- 
ease proper. 

Diagnosis. — The  affection  is  likely  to  be  confused  with  sciatica  and 
with  other  forms  of  inflammation  of  the  hip-joint. 

In  sciatica  the  limitation  of  motion  is  governed  by  the  amount  of 
pain  produced  by  the  movement  of  the  sensitive  parts  and  by  the  ten- 
sion on  the  ner\^e,  and  therefore  differs  from  that  resulting  from  true 
hip-joint  disease.  Flexion  is  usually  free  to  a  certain  limit,  but  impos- 
sible beyond  this,  and  if  the  leg  is  held  extended  on  the  thigh  this  is 
particularly  noticeable.  In  sciatica,  hyperextension  is  not  interfered 
with,  nor  rotation  nor  lateral  motion.  The  diagnosis  from  true  hip  dis- 
ease is  based  on  the  history  of  the  affection,  the  .t'-ray  appearances,  and 
'  Bruns  :  Beitr.  z.  klin.  Chir. ,  xl.,  650. 


ARTHRITIS  DEFORMANS.  219 

on  the  patient's  age — tuberculous  epiphyseal  ostitis  being  less  common 
in  adults. 

Treatment. — Morbus  coxae  senilis  or  arthritis  deform.ans  demands 
treatment,  first  to  relieve  the  pain,  and  secondly  to  correct  the  deform- 

ity. 

The  symptom  of  pain  is  rarely  so  great  as  to  cause  disability.  In 
such  cases  hot  baths,  massage,  galvanism,  hot  packs,  and  the  other 
measures  mentioned  are  often  of  use.  The  use  of  crutches  and  canes 
will  often  be  needed.  The  deformities  which  follow  this  affection  are 
usually  those  seen  in  hip  disease,  but  they  are  more  gradual  in  devel- 
opment. They  are  persistent  and  obstinate,  but  are  amenable  to  proper 
mechanical  treatment,  such  as  is  used  in  the  deformities  of  hip  disease.' 

Joint  irritation  from  overuse  is  to  be  met  here  as  elsewhere  by  rest 
to  the  joint.  The  use  of  the  protection  splint  described  in  hip  disease 
may  temporarily  be  necessary  when  the  joint  is  acutely  irritated. 

More  is  to  be  gained  ordinarily  by  gradual  correction  by  mechanical 
means  than  by  forcible  straightening  in  this  class  of  affections  of  the 
hip. 

KNEE. 

The  knee  is  one  of  the  large  joints  most  frequently  attacked..^by  this 
affection. 

Symptoms. — Pain,  irritability,  and  a  sense  of  stiffness,  especially 
after  sitting  a  while,  are  the  most  frequent  early  symptoms.  After 
walking  a  while  the  knees  feel  freer,  but  they  stiffen  up  after  rest  and 
are  also  painful  in  the  morning  on  waking.  Going  up-  and  down-stairs 
is  difficult  and  irritating.  The  whole  condition  at  first  seems  rather  an 
irritability  than  anything  more  serious,  and  the  patient  is  apt  to  disre- 
gard the  discomfort  and  to  do  considerable  walking,  on  the  ground  that 
walking  relieves  the  stiffness.  The  discomfort  is  increased  by  cold  and 
wet  and  by  overuse.     Acute  attacks  of  pain  and  swelling  may  occur. 

In  some  cases  the  affection  progresses  insidiously  and  gradually 
without  acute  attacks.  On  examination  in  the  early  cases  the  synovial 
membrane  is  somewhat  thickened  and  the  surface  depressions  of  the 
knee  are  filled  out.  There  is  perhaps  a  little  fluid  in  the  joint,  and 
movements  are  almost  always  attended  by  a  more  or  less  marked  grat- 
ing. This  phenomenon  is  due  chiefly  to  hypertrophy  of  the  synovial 
fringes,  which  are  rubbed  together  when  the  joint  is  moved.  It  is  also 
probable  that  the  same  sensation  can  be  produced  without  any  struct- 
ural change  by  mere  dryness  of  the  articular  surfaces. 

In  the  progressive  cases  and  in  those  of  longer  standing  the  painful 
symptoms  are  more  marked,  and  heat  and  tenderness  are  prominent, 
according  to  the  acuteness  of  the  symptoms. 

1"  Senile  Coxitis."     N.  Y.  Med.  Jour  ,  December  15th,  iSSS. 


220  ORTHOPEDIC  SURGERY. 

At  times  there  is  on  walking  a  sensation  of  catciiing  in  the  knee,  as 
if  something  had  been  squeezed  between  the  bones.  This  points  to  an 
hypertrophied  condition  of  the  synovial  fringes. 

The  first  limitation  of  motion  is  a  resistance  to  complete  extension, 
and  the  tendency  to  a  flexed  position  is  marked,  favoring  ankylosis  in 
this  position. 

In  general,  the  tendency  of  the  affection  is  toward  greater  and 


Fig.  192.— Enlargement  of  Knees  and  Ankles  from  Arthritis  Deformans  in  a  Child  of  Ten. 

Disease  of  long  duration. 

greater  impairment  of  the  joint  motion,  with  wasting  of  the  muscles 
and  atrophy  of  the  skin,  so  that  in  the  advanced  stages  one  can  see  a 
stretched  and  shining  skin  tightly  drawn  over  the  deformed  and  dis- 
torted joint. 

The  prognosis  depends  largely  upon  the  degree  of  change  in  the 
joint  surface  when  treatment  is  begun.     If  it  is  slight,  as  shown  by 


ARTHRITIS  DEFORMANS. 


221 


moderate  thickening  and  soft  grating  on  motion,  much  is  to  be  expected 
from  the  prevention  of  overuse  and  the  regulation  of  the  circulation  in 
the  knee.  If  the  changes  in  the  joint  are  advanced,  and  especially  if 
other  joints  are  showing  signs  of  a  progressive  involvement,  the  out- 
look is  unfavorable ;  not  that  life  is  likely  to  be  shortened,  but  that 
serious  disability  of  the  joint  most  often  results. 

Treatment When  pain  is  present  rest  is  very  strongly  indicated. 

A  few  days  will  generally  suffice  to  quiet  the  acute  symptoms.     Dur- 


FiG.  193.— Arthritis  Deformans,  Bony  Enlargement  of  Knees  with  Effusion.  Palpable  fringes. 
Limitation  of  motion.  Crepitus  and  pain  on  motion.  (By  the  courtesy  of  the  Department 
of  Surgical  Pathology  of  the  Harvard  Medical  School.) 


ing  the  quiescent  stage,  the  local  measures  described  above  should 
be  used.  If  pain  is  excessive,  one  has  to  face  the  dilemma  of  continu- 
ing motion  which  is  excessively  painful  or  of  allowing  the  patient  to 
rest  and  keep  the  joint  still,  by  which  process  one  is  likely  to  favor  the 
stiffening  of  the  joint,  if  it  is  continued  for  too  long  a  time.  For  short 
periods,  however,  there  is  no  risk,  and  sometimes  much  to  be  gained  by 
complete  rest  to  the  affected  articulation. 


222 


ORTHOPEDIC  SURGERY. 


When  ankylosis  of  the  knee  in  a  faulty  position  has  resulted  from 
arthritis  deformans,  brisement  force  is  to  be  tried  for  its  rectification, 
as  described  for  the  correction  of  ankylosis  after  tumor  albus.  It  is 
not,  of  course,  to  be  expected  that  motion  will  be  present  in  the  joint 
in  its  new  position,  for  the  structural  changes  must  have  already  been 

extensive  to  have  induced  the  de- 
forming ankylosis,  yet  some  motion 
may  be  preserved  in  the  joint. 

SHOULDER. 

The  shoulder  is  a  frequent  seat 
of  this  disease,  when  it  occurs  in  the 
monarticular  form.  When  one  shoul- 
der alone  is  affected  the  history  of 
injury  is  usual,  but  in  the  polyartic- 
ular forms  this  is  not  so  common. 
The  disease  may  first  manifest  itself 
to  the  patient  as  a  slight  attack  of 
joint  pain,  tenderness,  and  stiffness, 
and  from  this  condition  pass  into 
the  slow  chronic  course,  with  occa- 
sional exacerbations,  or  it  mav  begin 
insidiously.  The  amount  of  pain 
varies;  it  is  more  or  less  persistent, 
but  not  constant,  and  is  dull  and 
heavy  and  usually  worse  at  night. 
Stiffness  appears  at  this  time  with 
pain,  at  first  only  slight,  and  noticed 
in  forced  movements,  when  the  arm 
is  raised  above  the  level  of  the 
shoulder. 

As  the  disease  progresses  the 
muscles  waste,  and  in  severe  cases 
to  a  very  noticeable  degree.  A  creak- 
ing sensation,  both  on  active  and  passive  motion,  is  almost  alwa^'S  found 
by  placing  the  hand  over  the  joint.  Later  in  the  disease,  when  the 
characteristic  osseous  changes  occur,  the  arm  can  be  raised  but  a  short 
distance  from  the  side,  and  the  loss  of  muscular  power  is  great.  When 
the  changes  in  the  joint  have  taken  place  a  characteristic  appearance  of 
the  joint  is  found.  The  head  of  the  humerus  is  more  prominent  in 
front  of  the  joint,  while  behind  is  a  depression  as  if  the  head  of  the 
bone  was  displaced  forward,  while  the  shoulder  droops. 

The  treatment  does  not  differ  from  that  described  for  the  other 
joints. 


Fig.  194.— Arthritis  Deformans  Following 
Gonorrhoea.  Effusion  into  left  knee-joint 
with  subluxation  of  the  tibia.  Consider- 
able thickening  of  soft  parts.  Motion 
mostly  limited  bj'  pain.  [Involvement 
of  many  joints.]  (B3'  the  courtesy  of  the 
Department  of  Surgical  Pathology  of  the 
Harvard  Medical  School.) 


ARTHRITIS  DEFORMANS.  225 

WRIST. 

The  wrist  is  a  common  seat  of  this  affection,  with  the  ordinary 
symptoms  of  pain,  swelling,  stiffness,  creaking,  etc.  When  deformity 
has  occurred,  the  wrist  is  generally  flexed,  and  the  distal  ends  of  the 
radius  and  ulna  are  enlarged  and  project  backward.  Frequently  the 
hand  is  adducted,  this  often  being  associated  with  a  similar  distortion 
of  the  fingers. 

Arthritis  deformans  of  the  wrist  should  be  treated  on  the  principles 
already  indicated  for  these  affections. 

The  tcinporo-maxillary  joint  is  occasionally  affected  by  arthritis  de- 
formans. Massage  in  these  cases  can  be  given  by  the  finger  in  the. 
mouth,  as  the  affected  joint  is  more  easily  reached  from  the  inside. 


CHAPTER    VIII. 
OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS. 

Sprains. — Spine. — Spondylitis  traumatica. — Rupture  of  spinal  ligaments. — Hip. — 
Knee. — Lesions  of  the  tubercle  of  the  tibia.— Ankle. — Wrist. 

Chronic  synovitis.— Hip. — Knee. — Hypertrophy  of  villi.— Loose  bodies. — Lipoma. 
— Dislocation  of  semilunar  cartilages. — Cysts. — Trigger  knee. — Irritability 
secondary  to  flat-foot. — Ankle. — Shoulder. — Elbow.— Wrist. 

Bursitis. — Hip.  —  Knee. 

Habitual  dislocations. — Patella. — Shoulder. — Symphysis  pubis. 

Tumors  of  bones  and  joints. — Syphilis. — Spine. — Gout. — Ostitis  deformans. 

Arthropathy. — Spine. — Hip. 

Haemophilia. — Scurvy. — Secondary  osteoarthropathy. — Growing  pains. 

Actinomycosis. — Spine. — Myositis  ossificans. — Ankylosis. 

SPRAINS. 

The  name  sprain  is  used  to  designate  a  common  condition  caused 
by  wrenches  and  twists,  and  occasionally  by  blows  to  the  joints.  It  is, 
in  general,  the  result  of  some  sudden  force  moving  the  joint  beyond  its 
normal  arc  of  motion.  The  injury  may  be  most  marked:  (i)  to  the 
ligaments,  which  may  be  injured  or  torn ;  (2)  to  the  synovial  membrane, 
which  may  become  the  seat  of  an  acute  synovitis;  or  (3)  to  the  tendons 
surrounding  the  joint,  causing  a  tenosynovitis.  Any  one  of  these  or 
any  combination  of  them  may  exist  in  a  given  case. 

The  patJiology  of  the  affection  requires  no  especial  consideration, 
the  changes  found  being  simply  those  of  reaction  to  trauma  modified 
by  the  especial  tissue  affected. 

The  syviptoms  consist  of  pain,  more  or  less  severe,  and  tenderness, 
localized  at  the  point  of  the  chief  injury;  in  the  more  superficial  joints 
ecchymosis  of  the  subcutaneous  tissue  appears,  followed  by  swelling. 
The  function  of  the  joint  is  accompanied  by  pain,  often  severe  enough 
to  prevent  its  use.  A  period  of  greater  or  less  disability  follows,  dur- 
ing which  the  symptoms  diminish  in  severity,  and  in  favorable  cases 
entirely  disappear.  In  other  cases  a  condition  of  swelling,  irritability, 
and  impaired  function  persists,  spoken  of  as  "  chronic  sprain."  Sprains 
are  not  frequent  in  children,  in  comparison  to  adults. 

The  joints  most  frequently  sprained  are  the  ankle  and  wrist. 

The  diagnosis  from  fractures  is  important  and  is  to  be  made  with 
great  care. 

^\\Q.  prognosis  is  favorable  and  progress  is  hastened  by  treatment. 

Two  lines  of  treatment  are  recognized.  In  one  the  joint  is  fixed  by 
a  splint  or  plaster  bandage,  and  disuse  of  the  joint  is  depended  upon  to 

224 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.     225 

hasten  repair  and  the  absorption  of  the  blood  and  serum  poured  out. 
When  the  process  has  passed  the  acute  stage,  massage  and  douches 
are  generally  used  to  stimulate  the  circulation  and  hasten  recovery. 

In  the  other  method  of  treatment  the  attempt  is  made  directly 
after  the  injury  to  stimulate  the  local  circulation  by  massage,  etc.,  and 
thus  hasten  the  repair  while  the  joint  is  used  in  moderation.  The  lat- 
ter method  is  painful,  but  recov^ery  seems  to  be  hastened  by  it,  and  the 
circumstances  of  the  patient  are  frequently  the  determining  factor  in 
the  choice  of  methods. 

The  latter  method  is  carried  out  as  follows:  Immediately  after  in- 
jury the  joint  should  be  baked  in  a  hot-air  oven  for  half  an  hour  and 
massaged  for  a  few  minutes,  or  massage  alone  should  be  given  as  soon 
after  the  accident  as  possible.  Massage  should  then  be  given  twice  a 
day  for  periods  of  half  an  hour  each,  which  at  first  will  be  decidedly 
painful,  and  the  joint  should  be  used  moderately.  During  the  early 
part  of  the  treatment  the  joint  should  be  supported  by  an  elastic  flan- 
nel bandage  or  adhesive  plaster  strapping.  The  massage  periods  should 
gradually  be  separated  by  longer  intervals,  and  may  alternate  with 
douches  of  hot  followed  by  cold  water  to  the  affected  joint.  Various 
modifications  of  the  treatment  maybe  used;  hot-air  baths  may  take  the 
place  of  one  daily  massage  treatment  in  the  early  stages.  Vibratory 
massage  is  of  use. 

When  massage  follows  the  treatment  by  immobilization,  the  method 
does  not  differ  from  that  described. 

Spixe. 

Sprains  of  the  Spine. — After  a  severe  wrench  or  twist  of  the  spine 
or  after  some  accident  causing  extreme  motion  in  one  or  another  direc- 
tion, a  condition  of  pain  and  disability  ensues,  presenting  much  the  same 
symptoms  as  those  accompanying  sprains  in  the  other  joints.  Stiff- 
ness, pain,  and  perhaps  lateral  deviation  follow  a  painful  period,  during 
which  recumbency  is  generally  necessary.  As  such  cases  are  most  often 
treated  by  recumbency  on  a  sagging  mattress,  followed  by  sitting  up  as 
soon  as  possible,  these  cases  are  apt  to  drag  on  through  a  long  conva- 
lescence and  often  to  pass  into  the  chronic  condition  described  as  "  neur- 
asthenic spine."  It  is  better  that  cases  with  this  history  should  be 
recognized  as  chronic  sprain  of  the  spine,  to  which  nervous  symptoms 
have  been  added. 

When  the  chronic  stage  has  been  reached  there  is  but  little  ten- 
dency to  spontaneous  improvement,  and  the  diagnosis  from  spondylitis 
deformans  may  be  difificult. 

The  treatment  of  sprains  of  the  spine  should  consist  in  the  immedi- 
ate application  of  a  plaster  jacket  or  recumbency  on  a  gas-pipe  frame 
until  convalescence  is  established.  Then  should  follow  massage  and 
15 


226  ORTHOPEDIC  SURGERY. 

progressive  use  of  the  spine,  protected  by  the  jacket  or  a  spinal  support 
as  long  as  movement  is  painful. 

If  the  patient  has  reached  the  stage  of  chronic  irritability  of  the 
spine,  fixation  by  a  jacket  is  indicated,  followed  by  the  course  of  treat- 
ment just  described  for  convalescent  cases. 

Traumatic  Spondylitis. — Following  accident  some  weeks  or  months 
after,  there  develops  at  times  a  painful  and  stiffened  condition  of  the 
spinal  column,  accompanied  by  a  rounded  kyphus  of  greater  or  less  ex- 
tent, which  remains  as  a  permanent  condition.  Partial  paralysis  may 
occur. 

KiimmelV  who  originally  described  the  affection,  assumed  that 
there  existed  a  rarefying  osteitis,  but  this  assumption  has  not  been 
sufficiently  supported  by  post-mortem  evidence,  and  it  seems  likely 
that  the  condition  is  the  outcome  of  partial  and  compression  fractures ' 
of  the  vertebral  bodies  and  changes  in  the  shape  of  the  bodies  induced 
by  their  altered  static  relations.^  Certain  cases  described  under  this 
heading  are  perhaps  cases  of  arthritis  deformans  following  trauma  and 
wrongly  classified,  and  some  may  be  classed  in  all  probability  as  osteo- 
myelitis. The  prognosis  does  not  differ  from  that  of  spondylitis  defor- 
mans.    The  treatment  consists  in  rest  and  fixation  of  the  spine. 

Rupture  of  Spinal  Ligaments. — By  severe  traumatism  to  the  back, 
causing  extreme  flexion  c  f  the  spine,  there  may  occur  a  rupture  of  the 
posterior  spinal  ligaments  between  two  of  the  vertebrae.*  A  kyphus  is 
present  in  the  erect  position,  which  disappears  on  lying  down.  It  is 
accompanied  by  pain,  which  is  more  acute  in  the  upright  position.  The 
diagnosis  is  made  from  the  signs  described.  The  treatment  consists  in 
fixation  of  the  spine  by  a  brace  or  jacket  in  the  corrected  position. 

Hip. 

Sprains  of  the  hip  are  manifested  clinically  as  synovitis  of  that  joint 
and  are  described  in  that  connection. 

Knee. 

On  account  of  the  strength  of  the  muscles  and  ligaments  controlling 
the  joint,  gross  ligamentous  and  muscular  injury  is  rare  at  this  joint, 
the  results  of  trauma  being  generally  expressed  as  synovitis. 

Lesions  of  the  tubercle  of  the  tibia  have  been  described  by  Osgood,* 
in  which,  after  a  sudden  strain  falling  upon  the  partially  extended 
knee,  swelling  and  tenderness  of  the  tubercle  have  followed,  associated 

^  Deut  med.  Woch.,  1S95. 

-Reuter:  Arch.  f.  orth.  Chir.,  ii..  2,  137  (with  full  bibHography). 
HV.  A.  Lane:  Practitioner,  May.  1901. 

■* Painter  and  Osgood:  Boston  Med.  and  Surg.  Journ.,  January  2d,  1902  (with 
bibliography). 

=  R.  B.  Osgood:  Boston  Med.  and  Surg  Journal.  January  29th.  1903. 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.     227 

with  pain  on  complete  extension  of  the  leg.     The  condition  is  seen 
chiefly  in  boys  at  or  about  the  age  of  puberty. 

This  condition  would  seem  to  be  due  in  some  cases  to  an  inflamma- 
tion of  the  bursa  under  the  patella  tendon,'  and  in  others  to  an  injury 
of  the  partly  ossified  and  vascular  epiphysis  of  the  tubercle  of  the  tibia. 
A'-ray  appearances  are  apt  to  be  misleading,  as  during  the  normal  ossi- 
fication at  this  age  the  tubercle  appears  to  be  torn  loose  from  the  tibia 
below."  Only  when  there  is  a  marked  difference  in  the  radiographs  of 
the  two  knees  and  the  tibial  tubercle  is  displaced  upward  is  one  justified 
in  diagnosticating  any  displacement  of  it  by  force.  The  treatment  con- 
sists of  fixation. 

Ankle. 

On  account  of  its  flexibility  and  its  constant  liability  to  twists,  the 
ankle  is  the  commonest  location  of  sprains.  These  may  take  the  form 
of  injury  to  the  ligaments,  the  joint  membrane,  or  the  tendons.  The 
location  of  the  tenderness,  swelling,  and  pain  on  manipulation  will  serve 
to  identify  the  anatomical  location  of  the  injury. 

The  treatment  consists  either  in  fixation  in  a  stiff  bandage  or,  what 
is  in  most  cases  advisable,  in  immediate  massage  or  hot-air  baths,  or 
both.  Massage  should  at  first  be  given  twice  a  day,  and  should  be 
deep  and  thorough.  Moderate  use  of  the  foot  in  walking  is  desirable 
from  the  first,  except  when  it  is  excessively  painful  or  when  there  is 
severe  ligamentous  injury.  Walking  may  be  rendered  less  painful  by 
the  use  of  the  adhesive  plaster  strapping  described.  As  improvement 
progresses  the  massage  is  given  less  often  and  douches  of  alternating 
hot  and  cold  water  are  added  or  substituted. 

Chronic  Sprain. — In  many  cases  the  treatment  is  too  soon  discon- 
tinued after  sprains,  and  a  tenosynovitis  or  subacute  inflammation  of 
part  of  the  synovial  sac  may  persist  and  be  accompanied  by  local  heat 
and  tenderness.  It  matters  not  so  much  how  long  after  a  sprain  local 
heat  is  found  in  the  ankle-joint;  it  is  a  most  important  sign  and  indi- 
cates the  need  of  rest. 

In  other  cases  fixation  has  been  continued  too  long,  and  wasting  of 
the  muscles  and  disturbance  of  the  local  circulation  and  innervation 
have  induced  a  condition  of  irritability. 

In  such  cases  the  treatment  consists  of  measures  to  stimulate  the 
local  circulation  and  the  careful  and  graduated  resumption  of  use. 

Wrist. 

Sprains  of  the  wrist  may  affect  either  tendons,  ligaments,  or  synovial 
membrane.    The  treatment  does  not  differ  from  that  already  described. 
The  sprains  of  other  joints  do  not  require  especial  mention. 

'  Lovett:  Report  Boston  City  Hospital,  series  viii..  1897.  p.  345. 
■R.  W.  Lovett:  Phila.  Med.  Journ  ,  January  6th.  1900. 


22  8  ORTHOPEDIC  SURGERY. 


CHRONIC   SYNOVITIS. 


Chronic  serous  synovitis  is  also  known  by  the  names  of  dropsy  of  the 
joint,  hydrarthros,  hydrarthrosis,  hydrops  articulorum  chronicus,  etc. 
As  a  rule,  pathological  changes  are  present  in  the  synovial  membrane 
of  a  character  about  to  be  described ;  but  certain  cases  show  no  obvious 
pathological  changes  beyond  increase  of  fluid  for  a  long  time. 

Apart  from  the  cases  in  which  chronic  serous  synovitis  is  (i)  merely 
the  continuance  of  the  acute  condition,  its  cause  is  to  be  sought  (2)  in 
the  presence  of  some  mechanical  irritation  (such  as  hypertrophied  syno- 
vial fringes,  loose  bodies,  etc.),  (3)  in  the  presence  of  some  infectious 
process  (such  as  gonorrhoea  or  syphilis),  or  (4)  in  connection  with  some 
general  disturbance  (such  as  arthritis  deformans,  haemophilia,  etc.). 
Intermittent  synovitis  should  be  mentioned  as  not  coming  under  any 
one  of  these  heads. 

The  pathological  changes  in  simple  chronic  synovitis  are  represented 
by  increase  of  vascularity  and  thickening  of  the  synovial  membrane, 
with  hypertrophy  of  the  synovial  villi.  The  subsynovial  tissue  thickens 
in  cases  of  long  standing  along  with  the  capsule,  and  the  ligaments  may 
become  weakened  and  stretched. 

Intermittent  synovitis,  also  called  intermittent  hydrops,  is  a  well- 
recognized  but  rather  infrequent  affection,  accompanied  by  no  definite 
pathological  changes,  except  perhaps  a  little  laxity  or  thickening  of  the 
joint  capsule. 

The  knees  are  most  often  affected,  but  it  has  been  recorded  in  other 
joints.  No  etiology  has  been  formulated  for  the  condition,  the  sexes 
being  equally  affected  and  the  cases  pretty  evenly  distributed  through 
adult  life.  A  case  in  a  girl  of  nine  has  been  reported.  The  character- 
istic of  the  affection  is  a  non-inliammatory  serous  effusion  occurring  at 
more  or  less  regular  intervals,  lasting  a  few  days  and  disappearing  spon- 
taneously, to  return  again  and  again. 

No  satisfactory  treatment  has  been  formulated. 

Hip. 

Synovitis  of  the  hip  may  occur  in  children  or  adults.  It  may  follow 
.any  of  the  causes  producing  synovitis,  but  the  common  clinical  ante- 
cedents are  either  trauma,  rheumatism,  or  gonorrhoea.  Its  importance 
clinically  is  its  resemblance  in  children  to  tuberculous  hip  disease. 

After  a  fall  or  during  a  rheumatic  attack,  pain,  lameness,  muscular 
spasm,  flexion  deformity,  night  cries,  and  muscular  atrophy  may  be 
present  for  a  while.  These  symptoms  may  disappear  so  rapidly  that  one 
is  led  to  infer  that  synovitis  has  been  present  rather  than  tuberculosis 
or  acute  osteomyelitis. 

Twenty-one  cases  coming  to  the  clinic  of  the  Children's  Hospital  in 

/ 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.     229 

1897  and  1898,  which  presented  at  that  tune  some  or  all  of  these  s)'mp- 
toms,  were  found  in  1901-1902  to  have  entirely  recovered.  These 
were  part  of  a  series  of  ninety-five  cases  coming  in  those  two  years 
with  a  diagnosis  of  "hip  disease"  or  "synovitis  of  the  hip."  The 
duration  of  symptoms  in  most  of  these  cases  had  been  less  than  two 
weeks  at  the  time  of  examination.  Atrophy  was  present  in  more  than 
half,  limitation  of  motion  in  all,  lameness  in  all.  Complete  recovery  oc- 
curred in  these  cases  within  one  to  four  weeks  in  half  of  the  cases.'  In 
the  other  half  the  time  of  recovery  was  slower  or  could  not  be  formulated. 

In  children  the  diagnosis  of  synovitis  of  the  hip-joint  should  be 
made  only  when  recovery  has  occurred  in  a  few  weeks  and  has  proved 
permanent. 

Treatment. — In  children  cases  of  synovitis  of  the  hip-joint  are  to  be 
treated  in  the  same  way  as  cases  of  tuberculous  ostitis. 

Cases  in  adults,  which  are  clearly  to  be  recognized  as  synovitis, 
should  be  treated  by  rest  to  the  joint,  including,  if  necessary,  either 
traction  or  protection  by  apparatus,  followed  by  massage  and  stimula- 
tion of  the  local  circulation.  And  every  care  should  be  taken  to  guard 
against  using  the  unprotected  limb  too  soon. 

Knee. 

Chronic  Synovitis. — Chronic  serous  synovitis  is  at  times  the  sequel 
of  an  acute  or  subacute  attack.  In  such  a  case  the  acute  symptoms 
gradually  subside,  leaving  a  joint  somewhat  thickened  and  containing 
fluid.  If  the  condition  persists  the  muscles  become  weakened  and  re- 
laxed, and  lateral  mobility  may  be  present.  The  weakness  of  the  mus- 
cles is  itself  a  source  of  danger  and  may  lead  to  further  synovitis." 

At  other  times  the  chronic  synovitis  is  the  result  of  an  irritation 
caused  by  loose  bodies  in  the  joint,  displaced  semilunar  cartilages,  hy- 
pertrophied  synovial  fringes,  or  lipoma  arborescens.  The  continued 
strain  on  the  knees  induced  by  flat-foot  is  at  times  a  cause  of  chronic 
synovitis.  At  other  times  it  exists  in  connection  with  constitutional 
disease,  such  as  syphilis  and  gonorrhoea,  and  the  intermittent  form 
must  be  mentioned. 

The  treatment  of  the  chronic  form  which  has  lasted  over  from  the 
acute  stage  consists  in  fixation  if  heat,  pain,  and  tenderness  are  present, 
along  with  compression  by  bandaging  or  strapping  over  the  front  of  the 
joint  with  adhesive  plaster.  This  fixation  should  be  followed  by  mas- 
sage, hot-air  baths,  and  douches  to  restore  the  circulation,  along  with 
the  gradual  resumption  of  use. 

'"Diagnosis  of  Hip  Disease."  Boston  Med.  and  Surg.  Journ..  August  14th, 
1902. 

■Hoffa:  Berl.  klin.  Woch.,  xli.,No.  i. — Lovett:  Orth.  Trans. ,  xi.,  274. — Ten- 
ney  :  Annals  of  Surgery,  July,  1904. 


2  SO 


ORTHOPEDIC  SURGERY. 


If  the  synovitis  exists  as  the  result  of  mechanical  irritation,  the  irri- 
tating cause  should  be  removed  by  operation.  If  flat-foot  is  present  it 
should  be  corrected  by  plates. 

As  a  symptom  of  constitutional  disease,  treatment  of  the  systemic 


Fig.  795.— Right  Knee-joint  Bent.  Sagittal  section.  Joint  surface  slightly  separated,  show- 
ing the  infra-patellar  fat  pad,  and  the  bursa  under  the  patella  tendon  as  well  as  the  ex- 
tent of  the  joint  s^-novial  membrane.     (Fick.) 


condition  is  indicated.  In  resistant  cases  in  which  the  diagnosis  is  not 
clear,  the  joint  should  be  opened,  explored,  and  any  irritating  cause 
removed. 

Hypertrophy  of  the  Synovial  Villi. — This  affection  is  a  frequent 
cause  of  chronic  synovitis.  As  the  result  of  a  synovitis,  or  in  connec- 
tion with  continued  strain  of  the  knees  as  in  flat-foot,  or  in  arthritis 


OTHER   AFFECTIONS    OF  BONES  AND  JOINTS.    231 


deformans,  hypertrophy  of  the  synovial  fringes  occurs  to  an  extent  that 
makes  of  them  foreign  bodies.  As  sucli  they  are  a  source  of  continual 
irritation  in  the  joint.  The  symptoms  caused  by  them  are  pain,  effu- 
sion varying  at  times,  creaking,  occasional  catching,  and  some  swelling 
of  the  joint  membrane,  with  perhaps  tenderness.' 

The  treatment  at  first  should  consist  of  fixation  in  the  severer  cases, 
and  compression  by  plaster  strapping  over  the  front  of  the  joint  in  the 

milder  cases.  Douches,  massage,  and 
the  measures  suited  to  the  treatment  of 
chronic  synovitis  should  follow.  Flat- 
foot  should  be  corrected  and  the  knee  in 
general  placed  under  the  most  favorable 
mechanical  conditions  possible.  If  this 
does  not  control  the  affection,  the  joint 
should  be  opened  by  an  anterior  incision 
on  one  or  both  sides  of  the  patella,  the 
interior  of  the  joint  inspected  and  ex- 
plored, and  the  projecting  fringes  re- 
moved with  sharp  scissors  or  a  knife. 
The  bleeding  is  generally  slight.  The 
joint  may  or  may  not  be  irrigated,  ac- 
cording to  the  amount  of  bleeding ;  the 
capsule  should  be  stitched  and  the  skin 
wound  closed.  The  joint  should  be  fixed 
for  two  or  three  weeks,  after  which  pas- 
sive motion  and  graduated  use  are  begun. 
Loose  bodies  in  the  joints  are  found 
most  often  in  the  knee,  but  occasionally 
in  other  articulations.  The  other  names 
for  the  condition  are  loose  cartilages,  joint 
mice,  floating  or  movable  bodies  in  joints, 
etc.  They  can  be  divided  into  classes, 
according  to  their  structure,  as  follows: 
fibromatous,  lipomatous,  chondromatous. 
They  are  formed  in  one  of  the  following  ways : 
{a)  As  the  fibrinous  residue  of  an  exudation  or  blood  clot. 
{b)  As  lipomata  formed  in  the  joint  (see  Lipoma  of  the  knee-joint). 
(<r)  As  broken-off  osteophytes  in  arthritis  deformans. 
id)  As  hypertrophied  or  degenerated  synovial  tufts  (see  Hypertro- 
phy of  synovial  villi). 

{e)  As  marginal  ecchondroses  broken  off,  as  in  arthritis  deformans 
(see  Arthritis  deformans). 

'Painter   and    Erving:  "Chronic   \Mllous   Arthritis."     Am.    Journ.    of   Orth. 
Surg.,  November.  1903.  p    109. 


Fig.  ig 


. — Double  Chronic  Synovitis 
of  Knees. 


2  32  ORTHOPEDIC  SURGERY. 

(/)  As  encapsulated  foreign  bodies,  such  as  bullets  and  needles. 
(^)  As  bits  of  cartilage    or  bone    chipped  off  by  traumatism  or 


Fig.  197. — Right  Knee-joint  Flexed.  Seen  from  the  front.  Front  part  of  capsule  with  patella 
and  quadriceps  tendon  are  cut  above  joint  and  turned  down.  Between  the  condyles  is  seen 
the  liganientuni  mucosum,  running  from  the  sides  of  \vhich  are  seen  the  alar  ligaments. 
(Fick.) 


loosened  by  a  degenerative  process,  the  result  of  traumatism.'     The 

^  Lefebre  :  These  de  Paris.  1S91. — Ranzier :  Rev.  de  Med. ,  1S91,  p.  30 ;  Trans. 
Path.  Soc. ,  1896,  xlvii.-,  177. — Whitman,  Pediatrics,  1899,  vii.,  Xos.  4  and  5  (with 
bibliography). — Painter  and  Erving :  Boston  Aled.  and  Surg  Journ. ,  cxlviii., 
No.  12. 


OTHER   AFFECTIONS    OF  BONES  AND  JOINTS.    233 

fact  that  a  fall  may  be  the  cause  of  this  variety  of  loose  body  has  been 
clearly  proved. 

Loose  bodies  lie  free  in  the  joint  or  are  attached  by  a  slender  pedi- 
cle. They  may  vary  in  size  from  that  of  a  small  pea  to  that  of  a  horse 
chestnut,  and  are  of  all  shapes.  The  smaller  ones  are  most  often 
shaped  like  melon  seeds  or  are  irregularly  round,  while  the  larger  ones 
are  more  regularly  round,  concavo-convex,  or  spherical.  Sometimes 
they  are  facetted  and  crowded  together  like  the  carpal  bones,  and  again 
they  are  mulberry-shaped  or  pyriform.  In  one  joint  they  may  appear 
singly  or  in  great  numbers,  and  they  may  vary  a  great  deal  in  size  in 
the  same  joint.  0\'er  four  hundred  have  been  removed  from  one  knee- 
joint.  Next  in  frequency  to  the  knee  comes  the  elbow,  and  all  of  the 
larger  joints  are  liable  to  contain  these  bodies.     In  external  appearance 


Fig. 


-Lipoma  from  Knee-joint.     (C.  F.  Painter.) 


they  are  whitish  or  yellowish,  and  vary  from  a  soft  consistence  to  a 
bony  hardness.  On  section  they  show  either  a  plain  fibrous  structure 
or  a  fibrous  sheath  enclosing  a  mass  of  fat.  Again,  the  structure  is  of 
hyaline  or  fibro-cartilage,  ordinarily  without  corpuscles,  or  of  bone  tissue, 
most  often  without  Haversian  canals.  Frequently  they  present  a  com- 
bination of  two  of  these  forms. 

They  are  often  found  in  connection  with  the  changes  known  as 
arthritis  deformans,  and  also  in  joint  disease  of  various  types.  They 
may  be  found  in  connection  with  joint  tuberculosis.  In  certain  cases 
no  cause  can  be  assigned  for  their  occurrence. 

In  a  majority  of  cases  the  first  intimation  to  the  patient  that  anything 
is  wrong  is  that  while  in  the  act  of  walking  or  stooping  he  is  seized  with 
such  agonizing  pain  in  the  knee  that  he  may  fall  to  the  ground,  in  many 
cases  overcome  with  the  sensation  of  faintness  and  sickening  pain.  At 
times  this  pain  subsides  almost  immediately,  and  the  patient  is  able  to 


234 


ORTHOPEDIC  SURGERY. 


walk  within  a  few  minutes;  but  at  other  times  the  joint  remains  fixed 
in  a  position  of  more  or  less  flexion,  and  any  attempt  to  move  it  is  at- 
tended with  very  severe  suffering.  In  any  e\-ent,  such  an  occurrence  is 
apt  to  be  followed  by  an  attack  of  synovitis  lasting  several  days.  Up 
to  this  time  the  joint  may  have  been  normal  and  given  no  trouble,  or 
it  may  have  been  the  seat  of  chronic  inflammation.  These  attacks  are 
likely  to  be  repeated  without  any  assignable  cause.  On  manipulation 
of  the  joint  with  the  fingers  it  is  often  possible  to  detect  a  loose  body, 


Fig.  199.— Infrapatellar  Pad  Showing-  Tabs.     Left  knee.     (Tenney.) 

which  shifts  its  position  and  is  found  first  in  one  part  of  the  joint  and 
then  in  another.  The  most  common  spot  where  they  can  be  detected 
externally  is  in  the  pouch  over  the  external  or  internal  condyle  of  the 
femur.  They  are  felt  as  smooth,  slippery  bodies  under  the  skin,  which 
evade  the  fingers'  grasp  with  surprising  readiness.  Occasionally  they 
may  be  found  over  the  tibia  inside  the  ligamentum  patellae,  and  when 
one  of  these  substances  has  been  found  it  is  desirable  to  see  if  others 
are  present  in  the  joint.  Sometimes  it  is  impossible  to  detect  any  loose 
bodies  from  the  outside,  and  the  history  of  the  case  must  be  depended 
upon.'  In  some  cases  the  attacks  are  of  very  frequent  occurrence, 
'Hoffa:  Deut.  med.  Woch..  March  3d  and  loth,  1904. 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    235 

while  in  others  it  is  only  at  intervals  of  several  weeks  or  months  that 
the  joint  gives  any  trouble. 

With  repetition  of  attacks  the  joint  becomes  more  tolerant  and  the 
synovitis  less  severe.  In  cases  in  which  arthritis  deformans  is  present 
as  the  cause  of  the  loose  bodies,  the  history  of  the  attacks  is  less  typi- 
cal. The  patient,  however,  experiences  in  a  measure  the  same  sudden 
catching  of  the  joint,  and  movement  of  the  affected  knee  is  painful,  re- 
stricted, and  attended  with  a  particularly  distinct  grating. 

Finding  a  movable  body  which  can  be  slipped  from  place  to  place 
by  manipulation  establishes  the  diagnosis. 

In  cases  in  which  the  loose  body  cannot  be  found,  one  must  depend 
largely  upon  the  history,  making,  however,  frequent  examinations  un- 
der different  conditions  with  the  hope  of  ultimately  detecting  the  for- 
eign body. 

The  diagnosis  between  loose  bodies,  hypertrophied  synovial  fringes, 
and  dislocation  of  the  semilunar  cartilage  is  often  a  difficult  one  to 
make,  and  dependence  must  be  placed  chiefly  upon  tenderness  in  a  very 
small  spot  over  the  head  of  the  tibia  as  establishing  the  probable  occur- 
rence of  dislocation  of  one  of  the  semilunar  cartilages.  Diagnosis  has 
frequently  to  be  made  by  exploratory  incision. 

Treatment. — In  cases  in  which  the  loose  body  gives  but  little  incon- 
venience and  is  kept  from  passing  between  the  ends  of  the  bone  by  a 
knee-cap,  it  may  not  be  advisable  to  undertake  operative  treatment. 
In  other  cases,  especially  in  arthritis  deformans,  the  joint  may  have 
become  so  much  impaired  by  the  disease  that  even  if  a  foreign  body 
were  removed  little  would  be  gained.  In  the  great  majority  of  cases, 
however,  inasmuch  as  the  disease  occurs  in  otherwise  healthy  persons, 
mostly  young  adults,  any  operation  which  does  not  entail  serious  risk 
is  advisable. 

The  operation  is  performed  as  follows : 

The  loose  body  having  been  found,  a  needle  is  passed  through  it 
from  the  outside  to  steady  it,  and  it  is  then  cut  down  upon  b)'  careful 
dissection  until  it  is  exposed  and  removed.  After  the  removal  of  the 
body  originally  detected,  the  joint  should  be  carefully  examined  to  see 
if  others  are  present.  There  is,  of  course,  a  slight  tendency  to  the  re- 
formation of  these  bodies  after  one  or  more  have  been  removed. 

Lipoma. — Fatty  growths  may  form  in  the  joints,  acting  as  foreign 
bodies  and  causing  chronic  or  recurrent  attacks  of  acute  synovitis. 
Although  other  joints  are  not  exempt,  the  common  seat  of  occurrence 
is  in  the  knee. 

The  occurrence  of  such  growths  in  the  knee-joint  has  been  described 
in  the  form  of  the  lipoma  solitarium  of  Konig  and  as  the  lipoma  arbo- 
rescens  of  Miiller. 

The  lipomata  \-ary  in  size,  being  sometimes  as  large  as  an  Q.gg,  and 


136 


ORTHOPEDIC  SURGERY 


are  attached  to  the  synovial  membrane  by  a  pedicle.  In  shape  they 
may  be  regular  or  irregular  and  are  studded  with  small  tabs  of  fatlike 
tissue.  They  are  frequently  the  result  of  trauma,  and  are  formed  either 
by  the  intrusion  into  the  joint  of  the  perisynovial  fat  tissue  through  a 
slit  in  the  synovial  membrane,  or  they  are  the  result  of  inflammatory 
hyperplasia  of  the  articular  adipose  tissue '  or  of  the  synovial  villi.' 
Once  formed,  such  a  mass  acts  as  a  foreign  body,  and  clinically  a  swollen 
joint  is  found  with  little  or  no  effusion.  The  function  is  imperfect  and 
pain  may  be  present,  and  the  joint  is  liable  to  lock  in  partial  extension. 
The  swelling  is  chiefly  noted  at  the  side  of  the  patella  tendon.     The 


Fig.  2c«.— Tibial  Joint  Surfaces  of  Knee  Seen  from  Above,  vShowing  Semilunar  Cartilages. 

(Fick.) 

diagnosis  from  hypertrophied  villi  and  similar  conditions  is  difficult  and 
often  to  be  made  only  on  exploration.  The  treatment  consists  in  the 
removal  of  the  mass. 

Dislocation  of  the  Semilunar  Cartilages '  (Hey's  Internal  Derange- 
ment).— The  affection  is  nearly  always  traumatic  in  origin  and  consists 
in  the  tearing  loose  from  its  tibial  attachment  of  the  internal  or  exter- 
nal semilunar  cartilage.  The  internal  is  the  one  most  frequently  dis- 
placed.    This  is  probably  for  two  reasons :  first,  because  it  has  less  mo- 

^  Hoffa  :  Journ.  Am.  Med.  Assn.,  September  17th.  1904.  p.  795. 

-Painter  and  Erving :  Boston  Med.  and  Surg.  Journ.,  March  19th.  1903  (with 
literature). — Stieda :  Beitr.  z.  klin.  Chir.,  xvi..  2S5.  1S96. 

■^Hey:  "  Practical  Observations  in  Surgerj-,"  1S03. — W.  Bromfield  :  "  Chirurgi- 
cal  Observations,"  4  cases,  vol.  ii.,  1753. — Tenney :  Annals  of  Surgery.  July.  1904 
(with  bibliography).— Ferd:  Archiv  f.  Orth.,  i.,  2,  1903.— Bovin  :  Abst.  Am.  Journ. 
Orth.  Surgery,  vol.  i.,  p.  224. 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    237 

bility  on  the  tibia  than  the  external ;  and  secondly,  the  motion  most 
likely  to  displace  it  forcibly  is  outward  rotation  of  the  tibia  on  the  femur, 
or,  what  has  the  same  effect,  inward  rotation  of  the  femur  on  the  tibia. 
It  is  probable  that  some  looseness  of  the  ligaments  of  the  knee  is  asso- 
ciated with  the  injury  to  the  cartilage.  It  must  be  remembered  that 
the  knee  is  not  a  strictly  hinge  joint,  but  that  in  extension  the  leg  ro- 
tates outward  upon  the  thigh,  especially  at  the  end  of  extension,  when 
a  quick  outward  rotation  of  the  tibia  occurs,  locking  the  leg  in  complete 
extension. 

A  sudden  wrench  or  twist  in  slight  flexion  is  the  accident  most 
often  causing  displacement  of  these  cartilages. 

The  symptoms  are  in  a  measure  similar  to  those  caused  by  loose 
bodies,  and  similar  to,  but  generally  rather  more  than,  those  caused  by 
hypertrophied  synovial  fringes  and  the  like.     The  patient,  by  some  vio- 


FlG.  201.— Three  Right  Internal  Semilunar  Cartilages  Showing-  Fracture  Opposite  Internal 
Lateral  Ligament,  Upper  Surface.     (Tenney.) 

lent  muscular  effort  or  by  some  sudden  twist,  as  in  kicking  football  or 
falling  from  a  horse  or  carriage,  wrenches  the  knee  and  finds  it  impos- 
sible to  extend  it  fully,  and  walks  with  it  bent  in  the  way  described, 
suffering  much  pain.  This  sudden  locking  of  the  joint,  so  far  as  exten- 
sion is  concerned,  is  almost  the  only  characteristic  symptom  of  internal 
derangement ;  but  generally  on  examination  one  finds  a  protrusion  of 
one  of  the  semilunar  cartilages.  This  establishes  the  diagnosis,  and  a 
sharp  attack  of  synovitis  of  course  follows  such  a  severe  injury  to  the 
joint. 

In  some  instances  much  tenderness  can  be  found  over  the  inner 
tuberosity  of  the  tibia  where  none  is  present  over  the  outer  tuberosity. 

The  most  marked  cases  happen  after  some  serious  wrench  to  the 
joint.  Nevertheless,  cases  occur  in  which  the  cartilage  is  perhaps  only 
relaxed,  and  in  these  a  much  less  painful  locking  of  the  joint  arises. 
The  affection  is  masked  in  many  patients  by  the  severity  of  the  acute 


2^^ 


ORTHOPEDIC  SURGERY. 


synovitis  which  follows  the  injury,  and  the  true  character  of  the  acci- 
dent may  not  be  learned  for  a  long  time  afterward  unless  its  history  is 
most  carefully  inquired  into,  the  condition  in  this  case  passing  for  a 
simple  traumatic  synovitis.  One  occurrence  of  the  accident  predisposes 
to  subsequent  attacks.  Lateral  mobility  of  the  knee  is  likely  to  exist 
in  cases  of  long  standing. 

This  dislocation  affects,  for  the  most  part,  persons  between  twenty 
and  fifty  years  of  age;  men  are  much  more  frequently  affected  than 
women ;  it  rarely  occurs  in  children. 

Patients  who  are  liable  to  the  displacement  soon  learn  the  manipu- 
lation of  reduction  themselves.     The  knee  should  be  bent  to  its  fullest 

extent;  the  tibia  should  then  be 
drawn  away  from  the  femur  as 
far  as  possible,  to  separate  the 
joint  surfaces,  at  the  same  time 
rotating  the  tibia  inward  or  out- 
ward as  the  internal  or  external 
cartilage  is  displaced,  and  then 
the  leg  should  be  extended  quickly 
but  not  forcibly  to  its  fullest  ex- 
tent, while  the  surgeon  manipu- 
lates with  the  thumb  the  situation 
of  the  semilunar  cartilages,  es- 
pecially if  any  undue  prominence 
should  be  felt.  An  anaesthetic 
is  very  often  necessary  or  ad- 
visable. The  reduction  in  ex- 
ceptional instances  cannot  be 
effected,  but  commonly,  and  spe- 
cially with  the  use  of  an  anaesthet- 
ic, reduction  takes  place  easily  and 
a  distinct  click  is  heard  in  many 
cases. 

The  cartilage  may  after  reduction  become  united  to  the  tibia 
by  its  former  attachments  or  it  may  remain  loose,  to  cause  further 
attacks.  It  may  be  simply  torn  from  its  tibial  attachments  and  re- 
main attached  as  before  at  its  two  ends,  or  it  may  also  be  torn  across 
in  the  middle,  and  the  free  end  may  cause  trouble  by  acting  prac- 
tically as  a  loose  body.  Finally,  entire  detachment  of  the  torn 
piece  may  occur,  in  which  case  it  becomes  a  loose  body  of  the  car- 
tilaginous class. 

The  injuries  found  in  128  operations  for  the  relief  of  injured  semi- 
lunar cartilages  are  as  follows : ' 

'  Tenney  :  Loc.  cit. 


Fig.  202.— Semilunar  Cartilage  of  Right  Knee, 
Showing  Effects  of  Long-Continued  Fric- 
tion.    (Tenney.) 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    239 

Internal.     External. 

Torn  from  or  near  anterior  attachment 23  3 

Transverse    tear  at  or  near  lateral  ligament 38 

Longitudinal  split,  incomplete 16  i 

Longitudinal  split,  complete 8 

Turned  into  intercondylar  notch 3  i 

Loose.: 23  3 

Cystic I  I 

Ossified . .  i 

Doubtful I  5 

"3  15 

The  treatment  after  the  original  accident  is  reduction  of  the  dis- 
placed cartilage,  followed  by  the  usual  treatment  for  the  acute  synovitis, 
which  ensues. 

If  the  attacks  recur,  especially  on  slight  cause,  it  is  likely  that  the, 
cartilage  has  been  permanently  loosened  from  its  attachments  and  will 
be  in  all  probability  a  source  of  further  trouble.  The  treatment  may 
under  these  circumstances  be  mechanical  or  operative. 

1.  Mechanical  Treatment. — Although  the  use  of  knee-caps  with 
pads  beside  the  patella,  elastic  bandages,  etc.,  may  prove  of  use  in  pre- 
venting in  part  future  attacks,  they  can  hardly  be  recommended  as  a 
form  of  treatment  on  account  of  the  great  inconvenience  attending 
their  use,  and  the  fact  that  they  are  to  be  regarded  as  palliative  rather 
than  curative. 

The  mechanical  treatment  advocated  by  Shaffer '  for  this  condition 
is  as  follows :  The  treatment  is  the  application  of  an  apparatus  to  the 
thigh,  leg,  and  foot,  allowing  only  the  hinge  motion,  thus  preventing,  at 
least  in  large  measure,  the  slight  rotation  at  the  knee  occurring  in  ex- 
tension of  the  leg.  The  apparatus  also  is  arranged  by  a  stop-joint  at 
the  knee  to  prevent  complete  extension  of  the  knee.  It  consists  of  arL 
outside  upright  attached  to  the  boot  and  reaching  to  the  upper  part  of 
the  thigh,  and  an  inside  upright  reaching  from  the  upper  thigh  to  the 
upper  part  of  the  calf,  and  a  pad  is  placed  over  the  inner  aspect  of  the 
knee.  The  object  of  this  treatment  is,  by  preventing  harmful  motions- 
and  positions  for  some  months,  to  produce  a  reunion  of  the  cartilage  to 
its  proper  attachments  and  a  return  of  the  ligamentum  patellae  to  its. 
proper  length. 

2.  Operative  treatment  is,  as  a  rule,  surer,  quicker,  and  more  accept- 
able to  the  patient.  The  joint  is  opened  inside  or  outside  of  the  liga- 
mentum patellae,  according  to  the  cartilage  displaced,  by  a  vertical  ni- 
cision.  The  joint  should  be  explored  and  the  loose  part  of  the  cartilage 
removed.  The  joint  capsule  should  be  stitched  and  the  wound  closed. 
Fixation  should  follow  for  two  or  three  weeks,  after  which  passive  mo- 
tion and  massage  should  be  commenced. 

'Annals  of  Surgery,  October,  1898. 


240  ORTHOPEDIC  SURGERY. 

Cysts  of  the  Knee-joint. — Cystic  swellings  in  connection  with  the 
larger  joints,  especially  the  knee-joint,  occur  at  times/  These  swell- 
ings are  found  from  time  to  time  in  the  neighborhood  of  the  knee-joint, 
generally  in  the  popliteal  space.  At  first  there  is  nothing  to  suggest 
their  connection  with  the  joint  in  any  way,  for  the  cyst  may  be  at  a 
considerable  distance  from  the  joint.  There  may  be  no  fluctuation  to 
be  obtained  between  the  joint  and  the  cyst,  nor  can  the  fluid  from  the 
cyst  be  pressed  into  the  joint;  yet  such  cysts,  as  a  rule,  connect  with 
the  joint." 

The  affection  is  found  most  often  in  early  and  middle  adult  life. 
The  diagnosis  from  bursitis  is  often  difficult.  Extirpation  of  the  sac  is 
the  only  treatment  likely  to  be  of  use. 

Trigger  Knee. — The  so-called  trigger  knee,  described  also  as  genou 
a  ressort  or  schnellendes  Knie,  is  characterized  clinically  by  a  disturb- 
ance in  extension  of  the  leg.  Extension  is  normal  until  about  i6o°  is 
reached,  is  then  completed  with  a  snap  and  forcible  jerk,  during  which 
there  is  also  outward  rotation  of  the  tibia.  It  is  not  connected  with 
any  disease  of  the  knee-joint  nor  any  obvious  abnormality  save  loose- 
ness of  the  ligaments.  The  cause  is  evidently  a  disturbance  of  the 
movement  of  the  semilunar  cartilages,  particularly  the  external,  which 
is  caught  between  the  joint  surfaces  and  suddenly  freed,  producing  the 
jerk  described.  The  prognosis  in  children  is  good,  depending  upon 
tightening  of  the  ligamentous  structures  with  or  without  treatment. 
Mechanical  treatment  is  apparently  not  necessary,  at  least  in  children. '- 

Irritability  Secondary  to  Malpositions  of  the  Foot. — Certain  malpo- 
sitions of  the  foot  may  result  in  pain,  irritation,  and  synovitis  of  the 
knee-joint,  when  the  knee  is  affected  only  secondarily.  Such  disturb- 
ances occur  in  flat-foot,  pronated  foot,  and  shortening  of  the  gastrocne- 
mius muscle.     The  consideration  of  this  subject  will  be  taken  up  later. 

Ankle-Joint. 

Chronic  Synovitis. — Chronic  synovitis  is  most  likely  to  be  the  out- 
come of  the  acute  condition  which  for  some  reason  has  not  properly 
recovered.  In  cases  of  long  standing  the  circulation  and  innervation 
of  the  foot  and  leg  become  impaired,  and  swelling  and  congestion  occur 
in  connection  with  pain,  tenderness,  and  impaired  use.  Malpositions 
of  the  foot  may  occur,  the  most  common  being  a  limitation  of  dorsal 
flexion.  In  simple  chronic  synovitis  motion  is  generally  but  little  lim- 
ited and  not  very  painful,  or  but  slightly  so,  so  that  weakness,  swelling, 

'  St.  Bartholomew's  Hospital  Reports,  vol.  xiii.,  p.  245  ;  vol.  xxi.,  p.  177. 

^Cent.  f.  Chir.,  1898,  p.  585. 

''Trans.  Am.  Orth.  Assn.,  vol.  x.,  p.  40.— Thiem:  Monatsch.  f.  Unfallheilk., 
1896,  p.  182.— Rolen:  Ibid.,  189S,  377. — Nasse :  Deutsche  Chir.,  Lief.  66,  Heft  i^ 
p.  299. — Cotton:  Journal  Boston  Society  Medical  Sciences,  May,  1899. 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    241 

and  stiffness  of  the  joint  with  occasional  pain  are  the  only  symptoms 
complained  of. 

Tenosynovitis,  which  ma}'  exist  alone  or  in  connection  with  chronic 
synovitis,  gives  rise  to  swelling  around  the  tendons;  there  may  be 
some  puffiness  of  the  skin,  heat,  hyperaesthesia,  and  pain  on  certain 
movements  of  the  foot ;  but  extreme  change  in  contour  of  the  ankle  is 
not  present,  and  the  pain  is  chiefly  that  of  apprehension.  In  manipulat- 
ing the  foot  a  creaking  at  the  painful  spot  may  be  felt,  and  this  spot 
itself  is  sharply  localized,  and  as  a  rule  is  not  over  the  joint,  but  in  the 
course  of  the  tendons. 

Treatment . — If  heat,  pain,  and  irritability  are  present,  protection 
from  weight-bearing  by  the  use  of  crutches  is  indicated,  and  in  the  se- 
verer cases  fixation  of  the  joint  by  a  plaster-of-Paris  bandage  is  desir- 
able. Compression  is  of  value,  and  this  can  be  obtained,  with  some 
degree  of  fixation,  by  surrounding  the  front  and  sides  of  the  ankle-joint 
with  a  series  of  overlapping  straps  of  adhesive  plaster,  each  of  which 
starts  under  the  sole  of  the  foot,  passes  obliquely  over  the  top  of  the 
tarsus,  and  up  behind  the  ankle.  Applied  under  moderate  tension,  this 
dressing  is  an  efficient  and  comfortable  support. 

Following  this  stage  of  the  inflammation,  the  gradual  resumption  of 
use  is  indicated,  along  with  measures  to  stimulate  the  general  circula- 
tion, such  as  douches,  massage,  vibratory  massage,  hot-air  baths,  and 
Bier's  congestive  treatment. 

If  slight  valgus  position  exists  incidental  to  weakened  muscles,  it 
should  be  treated.  If  limitation  of  dorsal  flexibility  of  the  foot  is  pres- 
ent, it  should  be  corrected  by  stretching  the  gastrocnemius  muscle. 

Shoulder-Joint. 

Chronic  synovitis  of  the  shoulder  is  an  affection  existing  either 
as  a  sequel  of  an  acute  attack,  the  result  of  some  injury,  or  as  a 
slow,  persistent  process,  beginning  with  slight  symptoms  easily  disre- 
garded. 

The  earliest  symptom  to  attract  notice  is  stiffness,  observed  partic- 
ularly in  forced  movements,  as  in  placing  the  hand  on  the  head,  etc. 
Pain  is  a  variable  symptom. 

A  slight  fulness  about  the  joint  may  be  detected  at  this  time,  the 
humero-pectoral  groove  being  indistinct,  and  the  depression  below  the 
acromion  obliterated.  Although  an  increase  of  surface  temperature 
may  often  be  detected,  its  absence  is  of  little  importance,  the  joint  be- 
ing so  thoroughly  covered.  As  the  disease  progresses,  the  case  pre- 
sents an  exaggeration  of  the  early  symptoms ;  motion  becomes  more 
restricted,  swelling  increases  as  effusion  takes  place,  the  shoulder  appear- 
ing broader,  and  elevations  may  replace  the  natural  depressions.  Atro- 
16 


242  ORTHOPEDIC  SURGERY. 

phy  of  the  deltoid  and  scapular  muscles  gradually  occurs.  Pain  is  a 
symptom  of  var3dng  severity.  In  general,  the  tendency  is  toward  reso- 
lution with  more  or  less  impairment  of  joint  motion. 

Tenosynovitis  may  exist  and  simulate  closely  chronic  synovitis  of 
the  shoulder. 

Periarthritis  of  the  Shoulder. — Periart J  iritis  oi  the  shoulder-joint  has 
been  described  ^  as  a  condition  of  stiffness  not  infrequently  seen  after 
comparatively  slight  injuries.  Pain  accompanies  motion  beyond  a  cer- 
tain limit.  Atroph}^  of  the  muscles  is  present,  and  at  times  there  is 
some  spontaneous  pain.  The  arm  may  become  of  comparatively  little 
use.  The  diagnosis  of  periarthritis  is  not  based  on  pathological  evi- 
dence.^    In  most  cases  it  is  of  traumatic  origin. 

Treatment. — In  synovitis  of  the  shoulder-joint  with  any  active  in- 
flammation, the  indication  is  simply  for  rest  and  fixation.  These  are 
readily  secured  by  means  of  a  sling  and  a  bandage  securing  the  arm  to 
the  side.  It  is  important  to  mention  that  in  chronic  synovitis  of  the 
shoulder  the  weight  of  the  arm  dragging  upon  the  joint  structures  may 
be  a  factor  in  keeping  up  the  pain  and  irritation.  Consequently  in  the 
shoulder  the  use  of  a  supporting  sling  is  necessary  in  these  cases. 
Compression  will  be  needed  if  there  are  swelling  and  effusion.  Trac- 
tion may  be  required  in  the  severest  cases.  Fixation  should  not  be 
continued  longer  than  there  is  subacute  inflammation,  and  can  be  grad- 
ually discontinued ;  first  discarding  the  bandage  and  retaining  the  sling, 
which  can  be  discontinued  later.  So  long  as  muscular  irritability  ex- 
ists, rest  is  indicated.  In  these  cases  an  increased  arc  of  motion  and 
diminished  sensitiveness  will  usually  follow  a  few  days'  rest  of  the  joint, 
and  permanent  ankylosis  is  rendered  less  likely  by  the  application  of 
timely  immobilization. 

Fixation  should  be  followed  by  measures  to  restore  motion  and  to 
stimulate  the  circulation. 

The  question  of  the  use  of  forcible  passive  motion  in  the  convales- 
cent stage  does  not  differ  from  the  same  question  in  other  joints.  If 
the  stiffness  is  due  to  adhesions,  manipulation  under  an  anaesthetic, 
followed  by  massage,  etc.,  may  be  of  value ;  but  in  the  majority  of 
light  cases  gradual  passive  exercises  will  suffice.  Gentle,  graduated, 
passive  motion  carried  to  the  verge  of  being  painful,  with  the  use  of 
electricity,  is  of  great  advantage  in  many  cases  of  shoulders  stiffened 
from  a  slight  degree  of  chronic  joint  inflammation.  If  the  stiffness 
above  alluded  to  is  the  result  of  the  fixation  due  to  muscular  spasm, 
forcible  passive  motion  will  be  of  no  use,  as  the  reflex  spasm  will  reap- 
pear after  the  effect  of  the  anaesthetic  has  passed  away,  as  long  as  the 
disease  of  the  joint  remains. 

'  Duplay :  Arch.  Gen.  de  Aled.,  Paris.  1S72. 

-Jones  and  Allison:  N.  Y.  and  Phila   Aled.  Journal,  1904. 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    243 

The  treatment  of  tenosynovitis  and  periarthritis  does  not  differ 
essentially  from  that  just  described. 

Obstetrical  paralysis  of  the  shoulder  will  be  considered  in  a  later 
chapter. 

Elbow-Joint. 

Chronic  synovitis  may  appear  in  this,  as  in  other  joints,  from  the 
usual  exciting  causes,  and  presents  the  same  characteristics.  What  is 
popularly  spoken  of  as  a  "  tennis  elbow  "  is  a  chronic  synovitis  and  irrita- 
bility, in  which  injury  to  the  ligaments,  especially  to  the  internal  lateral 
ligament,  is  a  marked  feature.  It  results  from  the  strain  of  constant 
tennis-playing  or  some  similar  overuse  of  the  elbow,  and  its  treatment 
does  not  differ  from  that  of  a  similar  condition  in  other  joints. 

Wrist. 

Chronic  synovitis  may  occur  under  the  same  conditions  existing  in 
other  joints.  Tenosynovitis  is  characterized  by  pain  on  the  motion  of 
certain  fingers,  with,  perhaps,  a  sensation  of  rubbing  or  creaking  in  the 
affected  tendons.  Tender  points  are  present  in  the  course  of  these 
tendons.  In  the  superficial  tendons  of  the  wrist,  some  distention  of  the 
synovial  tendinous  sheath  can  be  seen. 

The  synovitis  of  other  joints  does  not  require  especial  mention. 

BURSITIS. 

Hip. — Inflammation  of  the  bursse  about  the  hip-joint  must  be  recog- 
nized as  a  condition  likely  to  give  rise  to  symptoms  possibly  resembling 
hip  disease.'  This  inflammation  is  most  often  traumatic,  but  may  be 
tuberculous.  Suppuration  and  the  formation  of  fistulas  may  occur. 
According  to  the  location  of  the  inflammation  the  symptoms  will  differ. 

The  chief  bursee  about  the  hip  are  as  follows :  The  subiliac  bursae 
under  the  ilio-psoas  tendon  as  it  leaves  the  pelvis ;  the  bursa  under  the 
insertion  of  the  tendon  of  the  ilio-psoas.  About  the  trochanter  major 
there  are  several :  one  between  the  fascia  lata  and  the  skin ;  a  less  con- 
stant one  between  the  fascia  lata  and  the  trochanter ;  one  under  the 
gluteus  medius ;  one  under  the  tendon  of  the  gluteus  minimus ;  one 
between  the  obturator  externus  and  the  gemelli;  one  for  the  pyri- 
formis ;  one  for  the  obturator  internus.  A  bursa  farther  removed  from 
the  hip-joint,  but  one  likel}'-  to  be  affected,  is  one  between  the  gluteus 
maximus  and  the  tuberosity  of  the  ischium.  This  affection  may  be 
mistaken  for  hip  disease,  as  there  are  limitation  of  motion  and  limp,  and, 
in  the  severest  cases,  suppuration.     The  diagnosis  at  times  can  be  es- 

'  Deutsch.  Zeit.  f.  Chir..  December.  1898.— Brackett :  Trans.  Am.  Orth.  Assn., 
1S96. — Lippert:  Beitr.  z.  klin.  Chir.,  .\1.,  503. 


244 


ORTHOPEDIC  SURGERY. 


tablished  only  after  incision.     The  treatment  consists  of  the  temporary 
use  of  crutches  and  incision  in  the  severer  cases. 

Bursitis  of  the  Knee. — The  various  bursse  about  the  knee  may  be- 
come inflamed  and  give  rise  to  disabihty,  often  of  an  obscure  nature. 

Housemaid's  Knee. — The  most  common  seat  of  this  affection  is 
in  the  prepatellar  bursa  which  lies  over  the  patella  and  part  of  the  liga- 
mentum  patellae.  This  is  not,  as  a  rule,  one  well-defined  sac,  but  con- 
sists of  three  layers  of  bursae 
more  or  less  well  marked 
and  generally  in  communi- 
cation with  each  other  and 
at  times  with  the  knee- 
joint.' 

This  affection  is  found 
chiefly  in  persons  whose 
occupation  leads  them  to 
spend  much  time  in  kneel- 
ing. The  acute  affection  is 
brought  about  by  over-use 
of  the  knee,  and  is  charac- 
terized by  slight  swelling, 
sensitiveness  on  pressure, 
and  discomfort  in  flexing 
the  knee,  which  is  localized 
at  the  site  of  the  bursa. 
Palpation  shows  a  more  or 
less  distinct  swelling,  which 
lies  over  the  patella  and 
which  is  rendered  more 
tense  by  the  flexion  of  the 
joint.  In  the  acute  stage  it  is 
likely  to  be  mistaken  for  sy- 
novitis of  the  knee-joint,  es- 
pecially as  the  inflammation, 
if  neglected,  tends  to  spread  and  the  swelling  may  become  more  diffuse 
and  burrow  around  the  joint;  although  the  chronic  enlargement  of  the 
bursa  is  sometimes  primary,  more  often  it  is  the  outcome  of  a  series  of 
acute  attacks.  Fluctuation  is  clearly  present,  and  the  swelling  is  more 
sharply  localized  to  the  region  in  front  of  the  patella  than  in  synovitis. 
In  the  chronic  stage  of  the  affection,  heat,  sensitiveness,  and  discomfort 
are  ordinarily  absent,  except  a  slight  feeling  of  stiffness  in  complete 
flexion  of  the  leg. 

For  diagnosis,  one  must  depend  upon  the  facts  that  the  swelling  is 
'  Bize  :  Journ.  d'Anat.  et  de  Phys.,  Paris,  xxxii.,  1S96,  p.  85. 


Fig.  203.— Prepatellar  Bursitis. 


OTHER  AFFECTIONS   OF  BONES  AND   JOINTS.     245 

entirely  in  front  of  the  patella,  that  the  patella  docs  not  float,  that  the 
joint  is  not  affected,  and  that  the  occupation  of  the  patient  in  some  way 
has  produced  continual  slight  injuries  of  this  region.  Although  the 
acute  affection  shows  a  tendency  toward  recovery  under  rest,  the 
chronic  affection  does  not  have  this  tendency  and  is  likely  to  continue 
unabated. 

Suppuration  occurs  in  both  acute  and  chronic  varieties  in  a  certain 
proportion  of  cases.  The  inflammation  of  the  bursa  occasionally  occurs 
in  connection  with  gout,  rheumatism,  or  syphilis. 

Treatment. — The  acute  affection,  unless  too  far  advanced,  ordinarily 
yields  readily  when  the  limb  is  placed  in  the  extended  position  upon  a 
ham  splint  and  the  constant  irritation  of  walking  is  avoided.  The  appli- 
cation of  pressure  is  of  much  assistance  in  allaying  the  inflammation ; ' 
a  few  days  or  weeks  in  the  milder  cases  will  ordinarily  reduce  the  in- 
flammation. In  old  cases  this  treatment  has  little  or  no  effect.  If, 
however,  the  bursitis  has  reached  the  stage  of  suppuration,  incision 
affords  the  only  hope  of  relief. 

In  chronic  bursitis  the  most  satisfactory  treatment  is  to  lay  the  entire 
bursa  open  by  a  crucial  incision  and  dissect  out  the  tough  fibrous  sac. 

Bursitis  of  the  Deep  Prepatellar  Bursa. — The  affection  of 
this  bursa  presents  certain  characteristic  symptoms  often  difficult  to 
differentiate  from  those  of  synovitis.  This  bursa  lies  beneath  the  liga- 
mentum  patellae  next  to  the  tibia. ^ 

The  inflammation  of  this  bursa  is  described  under  various  names, 
one  of  them  hQ.\ng  ps  en  dart /uvse  du  genon^ 

The  peculiar  symptoms  of  this  affection  are  pain  in  complete  exten- 
sion of  the  leg,  referred  to  the  tubercle  of  the  tibia ;  pain  and  tender- 
ness, referred  to  the  patella  tendon ;  apparent  enlargement  of  the  tuber- 
cle of  the  tibia,  and  bulging  at  the  sides  of  the  ligamentum  patellae. 
The  affection "  may  be  mistaken  for  inflammation  of  the  superficial 
pretibial  bursa  or  for  the  inflammation  of  abnormal  bursae  in  this 
neighborhood.  Careful  examination  will  usually  differentiate  it  from 
synovitis  of  the  knee-joint.     Tuberculosis  of  this  bursa  may  occur. 

The  treatment  does  not  differ  from  that  of  housemaid's  knee  except 
that  bursitis  of  the  deep  pretibial  bursa  is  more  obstinate. 

The  inflammation  of  other  bursae  about  the  knee-joint  presents  no 
peculiar  symptoms,  and  the  existence  of  the  affection  is  made  evident 
by  the  presence  of  a  fluctuating  swelling  at  the  site  of  a  bursa. 

'  Hoffmann:  Am.  Journ.  of  Orth.  Surger}',  vol.  ii.,  2. 

-  Lovett :  Boston  City  Hosp.  Reports,  8th  series,  p.  345. 

•'Dubreuil:  Annales  d'Orth..  Paris,  September,  1S90. — "Traitede  Path.  e.\t." 
(Follin),  iii.,  19. — Pitha  and  Billroth  :  "  Chirurgie."  iv..  i.  Heft  2.  p.  242. 

■•Osgood:  Boston  Med.  and  Surg.  Journ..  January  29th.  1903  (with  literature). 
—  Lovett:  Phila.  Aled.  Journ.,  January  6th,  1900. 


246  ORTHOPEDIC  SURGERY. 

Bursitis  '  of  the  Shoulder. — Although  this  affection  may  simulate 
synovitis,  the  limitation  of  motion  induced  by  it  is  only  in  certain  direc- 
tions, and  tenderness  and  swelling  are  chiefly  confined  to  the  affected 
structures.  The  bursae  most  frequently  affected  are  those  of  the  sub- 
scapular, the  deltoid,  and  the  coracoid  regions.  The  disease  is  generally 
tuberculous. 

HABITUAL   OR   RECURRENT    DISLOCATIONS. 

Patella. — Dislocation  of  the  patella  or  slipping  patella  is  likely  to 
occur  either  spontaneously  or  for  very  slight  cause  in  certain  young 
girls  with  lax  muscular  fibre  and  a  feeble  development,  and  boys  are 
only  exceptionally  attacked.^ 

In  consequence  of  some  slight  twist  of  the  leg,  as  in  dancing,  rising 
from  a  chair,  going  upstairs,  or  some  similar  motion,  an  excruciating 
pain  is  felt  in  the  knee,  and  the  person  either  falls  in  consequence  of 
faintness  or  finds  herself  unable  to  use  the  leg.  Very  often  the  patient 
herself  hears  a  cracking  sound  when  the  dislocation  occurs.  The  patella 
is  found  almost  always  dislocated  outwardly,  sometimes  twisted  so  that 
its  lateral  edge  rests  against  the  front  of  the  femur  (vertical  luxation  of 
Malgaigne).  The  reduction  of  the  dislocation  is  very  simple  and  is  very 
soon  learned  by  the  patients  themselves.  The  leg  is  fully  extended  and 
the  patella  gently  pressed  back  into  place  until  it  assumes  its  proper 
place  with  a  click,  or  often  it  slips  back  of  its  own  accord  when  the  leg 
is  straightened.  An  attack  of  synovitis  follows,  as  in  the  case  of  loose 
bodies,  but  the  joint  soon  acquires  a  tolerance  so  that  each  succeeding 
attack  of  synovitis  becomes  less. 

The  cause  of  the  affection  seems  to  be,  in  most  cases,  the  lack  of 
tonicity  in  the  extensor  muscles  of  the  thigh,  or  the  elongation  of  the 
ligamentum  patellae,  but  very  commonly  the  former. 

After  many  attacks  of  dislocation  the  patients  complain  of  a  certain 
sense  of  insecurity  in  walking,  which  in  severe  cases  may  amount  to  a 
distressing  disability,  limiting  the  patient's  ability  to  walk  or  engage  in 
active  occupation. 

Mechanical  Treatment. — If  an  elastic  knee-cap  is  split  in  front  and 
furnished  with  lacings  or  straps,  and  if  felt  pads  are  sewed  upon  the  sides 
of  the  cap  at  such  places  as  would  exert  pressure  upon  the  sides  of  the 
patella,  an  arrangement  is  furnished  which,  when  properly  adjusted, 
will  give  a  serviceable  support  in  lighter  cases,  allowing  motion  at  the 
knee. 

The  following  steel  appliance  will  be  found  of  service:  It  consists 
of  two  uprights,  hinged  at  the  knee,  extending  from  the  middle  of  the 
calf  to  the  middle  of  the  thigh  on  each  side  of  the  limb,  and  connected 

'  Blauvelt :  Beitr.  z.  klin.  Chir. ,  xxii. — Ehrhardt :  Arch.  f.  klin.  Chir.,  1900,  xl. 
-Bade  :  Zeit.  f.  orth.  Chir.,  xi.,  3. 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    247 

with  cross-pieces  above  and  below.  To  these  are  attached  at  the  level 
of  the  middle  of  the  patella  semilunar  plates,  which  are  of  such  a  shape 
and  are  bent  in  such  a  way  as  to  press  upon  the  sides  of  the  patella. 
They  are  covered  with  padding  and  leather.  If  leather  straps  pass  diag- 
onally from  the  uprights  to  buttons  upon  the  top  and  bottom  of  these 
plates,  an  adequate  amount  of  side  pressure  will  be  secured.  Two 
straps  from  underneath  the  knee  prevent  the  apparatus  from  falling 
forward,  and  the  straps  mentioned  prevent  the  apparatus  from  slipping 
backward.     It  is  essential  that  this  appliance  should  not  remain  in  a 


Fig.  204. — Dislocation  of  Patella. 

bent  position,  as  the  pressure  at  the  sides  of  the  patella  would  in  that 
case  be  diminished.  To  prevent  this  a  spring  is  furnished,  connecting 
the  upper  portion  of  the  upright  with  the  lower  portion,  with  sufficient 
strength  to  force  the  appliance  into  a  straight  position,  but  allowing 
bending  of  the  knee  by  muscular  effort. 

Some  such  retentive  apparatus,  along  with  the  use  of  massage  and 
electricity,  may  effect  a  cure,  especially  in  rapidly  growing  girls. 

Operative  Treatment. — In  resistant  cases,  or  those  unable  to  follow 
out  proper  mechanical  treatment,  operation  will  be  required.' 

This  consists  in  the  removal  of  an  elliptical  piece  of  the  front  of  the 
'  Bade  :  Zeit.  f.  Orth.  Chir..  xi.,  3.  451  (with  bibliography). 


248  ORTHOPEDIC  SURGERY. 

capsule  of  the  joint  internal  to  the  extensor  tendon  and  a  stitching  to- 
gether of  the  edges  of  the  opening,  thereby  tightening  the  inner  part  of 
the  capsule/ 

In  resistant  cases  a  vertical  incision  outside  of  the  patellar  tendon 
must  also  be  made  to  allow  the  patella  to  be  pulled  into  place  by  the 
tightening  of  the  capsule  on  the  inner  side. 

The  tubercle  of  the  tibia  may  be  transplanted  ^  farther  in  on  the  tibia, 
or  the  patella  tendon  may  be  split  longitudinally  and  the  inner  half  car- 
ried under  the  outer  and  attached  to  the  tibia  outside  of  the  tubercle/ 

Habitual  or  recurrent  dislocation  of  the  shoulder  becomes  at  times 
.^n  affection  requiring  orthopedic  treatment. 

The  causes  of  the  condition  may  be  formulated  as  follows :"  \.  Lax- 
ity of  the  capsule  of  the  joint.  2.  Partial  fracture  of  the  head  of  the 
humerus.  3.  Partial  fracture  of  the  glenoid  cavity.  4.  Tearing  away 
of  muscular  insertions  and  rupture  of  tendons.  5.  Abnormality  in  the 
shape  of  the  head  of  the  humerus  not  demonstrably  due  to  fracture. 

It  would  seem  as  if  in  certain  instances  the  cause  of  the  recurrence 
of  the  dislocation  was  insufficient  immobilization  of  the  arm  after  a  pri- 
mary dislocation. 

The  atrophy  of  certain  muscles  seems  to  be  characteristic  in  these 
cases  in  a  series  observed  by  one  of  the  writers.^  These  are  the  cora- 
cobrachialis,  triceps,  deltoid,  especially  the  posterior  part,  supra-  and 
infraspinatus,  rhomboids,  levator  anguli  scapulae,  and  latissimus  dorsi. 
Limitation  of  motion  is  not  so  much  due  to  pain  or  to  fear  of  displace- 
ment as  apparently  to  some  lesion  in  the  joint  mechanism.  It  should 
be  noted  that  a  large  proportion  of  epileptics  are  found  in  all  reported 
cases.  Reduction  is  as  a  rule  easy,  and  inflammatory  reaction  in  the 
joint  is  notably  slight  or  even  wholly  absent  after  reduction. 

Prognosis. —  In  a  shoulder-joint  in  which  a  dislocation  has  once  or 
twice  occurred  from  insufficient  cause,  it  is  not  likely  that  the  liability 
will  become  less  frequent  as  time  advances  if  no  treatment  is  under- 
taken. As  a  rule,  the  dislocations  will  occur  with  greater  frequency 
and  from  slighter  causes  as  time  progresses. 

Treatment. — -The  methods  of  treatment  are: 

By  apparatus ;  by  massage  and  exercises  alone ;  by  temporary  fixa- 
■  tion  and  massage ;  by  operation. 

The  use  of  apparatus  confining  the  arm  to  the  side  is  to  be  con- 

^N.  Y.  Med.  Record,  April  20th,  1S95. — Trans.  Am.  Orth.  Assn..  vol.  viii..  p. 
227. — Ibid..,  vol.  viii.,  p.  237. 

■^Annals  of  Surg.,  1899. 

^  Goldthwaite :  Am.  Joum.  Orth.  Surgery,  vol.  i.,  No.  3. 

"*  Stimson :  "Dislocations,"  p.  265,  quoting  also  Gurlt,  "Path.  Anat.  der  Ge- 
lenkkrankheiten,"  p.  250.  — Gushing :  Med.-Chir.  Trans..  1S37.  p.  336. 

°Burrelland  Lovett :  Am.  Jour.  Med.  Sciences.  August,  1S97. 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    249 

demned.  It  weakens  the  muscles  by  causing  their  disuse.  It  is  un- 
comfortable and  partially  disabling,  and  its  use  can  be  considered  justi- 
fiable only  temporarily  or  under  exceptional  conditions. 

An  apparatus  used  by  one  of  the  writers  seems  as  little  objection- 
able as  any.  It  consists  of  a  leather  shoulder  cap  embracing  the  arm, 
strengthened  by  two  steel  strips,  one  horizontal  strip  running  from 
before  backward  and  fitting  the  outer  contour  of  the  shoulder.  The 
other,  a  longitudinal  strip,  runs  from  the  base  of  the  neck  to  the  middle 
of  the  outside  of  the  arm.  There  is  a  joint  connecting  the  two  steel 
strips  opposite  the  shoulder,  allowing  antero-posterior  motion  in  the 
shoulder.  The  shoulder  cap  is  fastened  in  place  by  a  chest  band ;  the 
apparatus  prevents  abduction  of  the  arm  to  any  degree  likely  to  pro- 
duce dislocation. 

Fixation  for  some  time  is  called  for  when  a  second  dislocation  has  oc- 
curred from  slight  cause.  The  arm  is  lifted  by  applying  a  sling,  which 
supports  the  forearm  and  point  of  the  elbow.  The  arm  is  held  to  the 
side  by  a  swathe,  thus  preventing  all  motions  of  the  joint.  This  re- 
moves as  much  weight  as  possible  from  the  joint  capsule. 

Such  cases  have  been  operated  upon  successfully  by  reefing  the  an- 
terior part  of  the  capsule  of  the  joint  through  an  anterior  incision.' 

Symphysis  Pubis. — Relaxation  of  the  joint  in  the  symphysis  pubis 
occurs  at  times  during  pregnancy,  so  that  walking  becomes  difficult  or 
impossible.  After  delivery  the  abnormal  condition  may  disappear  or 
may  persist  as  a  source  of  disability.  It  is  best  treated  by  a  leather  or 
plaster  jacket  fitting  tightly  over  the  sacrum  and  ilia,  along  with  as 
much  limitation  of  walking  as  may  be  necessary. 

TUMORS   OF   THE    BONES   AND   JOINTS. 

Primary  tumors  of  bone  belong  to  the  group  of  connective-tissue 
tumors.  The  periosteum  and  bone  marrow  form  the  matrix  for  their 
development.  These  tumors  correspond  to  the  various  types  of  connec- 
tive tissue,  fibrous,  mucoid,  cartilaginous,  and  osseous.  Among  pri- 
mary tumors  are  to  be  classed  sarcomata.  Secondary  tumors  of  any 
kind  may  occur,  among  the  latter  being  carcinoma.  Angioma,  hEcma- 
toma,  echinococcus  cyst,  and  aneurism  must  be  mentioned  as  other 
possibilities. 

Exostoses. — Apart  from  the  changes  of  arthritis  deformans,  there 
sometimes  occur  exostoses  about  the  articular  ends  of  the  bones,  which 
are  very  rarely  large  enough  to  impede  the  motion  of  the  joints ;  at 
other  times  they  are  troublesome  by  involving  tendons  in  their  growth. 

'Cent.  f.  Chir.,  1883.  p.  28;  Beilage  z.  Cent.  f.  Chir.,  1SS2.  p.  73,  and  1SS6.  p. 
90:  Deutsch.  Zeit.  fiir  Chir.,  1S80,  xiii.,  p.  167  — Pitha  and  Billroth,  ii..  p.  652. — 
"Aseptic  and  Antiseptic  Surgery."  p.  8. — Bull,  de  I'Acad.  de  Med..  1894.  p.  334. — 
Burrell  and  Lovett :  Am.  Jour.  Med.  Sciences,  August,  1897. 


250 


ORTHOPEDIC  SURGERY. 


Cartilaginous  exostoses  in  the  neighborhood  of  the  joints  have  occa- 
sionally a  capsule  overlying   the  layer  of  cartilage  corresponding  in 

stiucture  to  synovial  membrane.     This  con- 
dition is  spoken  of  as  a  bursate  exostosis. 

CJiondromata  grow  most  frequently  from 
the  bones  of  the  hand.  They  are  often  mul- 
tiple, occur  most  often  in  children  and  young 
adults,  and  may  be  congenital.  Myxomata 
"ind  lipoviata  are  rare  in  the  bones. 

Sarcomata  originate  in  the  marrow  or 
pcno^iteum.  If  they  contain  bony  tissue  they 
die  spoken  of  as  osteosarcomata.  Joint  sar- 
comata affect  chiefly  young  subjects  from 
fitteen  to  twenty-five  years  old,  and  the 
loints  commonly  affected  are  the  knee,  shoul- 
dei,  and  wrist.  Central  sarcomata  are  more 
likeU  to  invade  joints  than  are  the  periosteal 
grow  ths.  Males  are  slightly  more  liable  than 
females  to  be  affected. 

Carcinomata  of  bone 
may  occur  secondarily 
from  extension  or  me- 
tastasis. They  occur  in 
circumscribed  nodes  or 
as  a  diffuse  infiltration. 
The  latter  form  is  usually 
accompanied  by  prolifer- 
ation of  the  periosteum 
and  absorption  of  the 
substance  of  the  bone. 
This  is  at  times  re- 
placed by  soft  new  bone, 
and  a  condition  may  be 
present  resembling  lo- 
cally osteomalacia  and 
known  as  carcinomatous 
osteomalacia. 

\Mth    this    form,    as 
with  primary  new  growths,  spontaneous  fracture  ma}'  occur. 


Fig.  205. — Tumor  of  Femur  Involving  Knee. 


Malignant  Disease  of  the  Spine. 


Sarcoma  and  carcinoma  of  the  vertebral  column  are  occasionally 
met.     Carcinoma  has  been  noted  following  similar  disease  of  the  breast 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    251 

and  testicle,  and  less  frcquentl}'  of  the  stomach.  The  occurrence  may 
be  from  direct  extension  or  from  general  infection. 

The  disease  usually  begins  as  an  infiltration  of  the  spongy  tissue  of 
the  vertebral  bodies,  which  is  gradually  replaced  by  the  malignant 
growth.  There  may  be  but  little  change  in  the  appearance  of  the  bod- 
ies, but  these  will  be  found  converted  into  a  soft,  friable  mass.  De- 
struction of  the  bone  substance  with  deformity  may  occur. 

The  most  frequent  site  of  malignant  disease  is  in  the  lumbar  region, 
and  the  next  commonest  location  is  in  the  dorsal  vertebrae. 

The  disease  may  pursue  an  insidious  course,  and  not  be  suspected 
until  found  at  the  autopsy.     This,  however,  is  rare,  and  a  serious  affec- 


FlG.  206. — Sarcoma  of  Spine. 

tion  is  usually  evident,  even  though  no  diagnosis  is  made.  The  symp- 
toms are  similar  to  those  of  Pott's  disease,  pain  being  very  prominent, 
wdth  frequently  paralysis.  Both  are  the  result  of  the  encroachment  of 
the  growth  on  the  spinal  nerves  and  cord.  The  location  of  the  pain 
will  depend  on  the  site  of  the  diseased  vertebrae,  and  it  is  usually  in- 
creased by  pressure  and  motion,  and  it  extends  in  the  arms,  trunk,  or 
legs.'  The  paralysis  usually  follows  a  disturbance  in  sensation,  and  is 
due  to  compression  from  extension  of  the  disease  or  from  involvement 
of  the  meninges.  It  maybe  partial  or  complete,  and  as  a  rule  does  not 
occur  suddenly.  Tenderness  over  the  spine  is  an  uncertain  sign,  and 
probabl)'  has  no  diagnostic  importance.  When  deformity  occurs  it  will 
'  Edes  :  Bost.  Med.  and  Surg.  Jour..  June  17th,  1SS6,  539. 


2  52  ORTHOPEDIC  SURGERY. 

be  found  to  present  a  more  rounded  prominence  than  is  usually  seen  in 
Pott's  disease.  Hemorrhage  from  the  bowels  or  hsematuria  has  been 
observed. 

When  following  malignant  disease  elsewhere,  which  can  be  recog- 
nized, the  diagnosis  should  present  no  special  difficulty,  but  in  other 
instances  it  is  usually  hard  or  even  impossible.  It  should  be  distin- 
guished from  aneurism  of  the  aorta,  cervical  pachymeningitis,  and  Pott's 
disease. 

The  prognosis  needs  no  comment ;  a  fatal  end  is  only  a  matter  of 

time. 

Malignant  Disease  of  the  Hip. 

The  variety  of  tumor  which  most  often  affects  the  head  of  the  fe- 
mur in  young  children  is  a  round-cell  sarcoma  of  the  periosteum.  But 
the  epiphysis  is  rarely  the  seat  of  the  tumor.  In  seventy  cases  of  sar- 
coma of  the  femur,  analyzed  by  Gross,  there  were  only  two  cases  in 
which  the  upper  epiphysis  was  affected. 

The  early  symptoms  in  cases  in  which  the  head  of  the  femur  is  not 
primarily  involved  are  very  slight,  and  consist  chiefly  of  a  swelling 
which  is  painless  and  not  fluctuating;  limp  and  slight  restriction  of 
motion  may  be  present.  Soon,  however,  it  becomes  evident  that  the 
enlargement  is  predominating  over  all  the  other  symptoms  and  the  swell- 
ing progressively  increases,  suggesting  perhaps  hip  abscess.  Fluctua- 
tion, however,  is  absent  and  the  swelling  embraces  the  whole  circum- 
ference of  the  limb.  There  is  an  enlargement  of  the  superficial  vessels 
and  the  swelling  later  becomes  enormous.  The  patient  becomes  ema- 
ciated and  wastes  away.  The  affection  may  be  very  painful  or  again  it 
may  be  attended  with  very  little  suffering.  Amputation  at  the  hip- 
joint,  if  performed  sufficiently  early,  is  the  only  remedy. 

SYPHILIS. 

Acquired  syphilis  may  present  joint  manifestations. 

Arthralgia  without  objective  symptoms  may  occur  early  in.  the  sec- 
ondary stage.  Simple  serous  synovitis,  associated  with  pain,  redness, 
and  swelling,  may  accompany  the  secondary  symptoms.  This  condition 
"may  pass  on  to  a  chronic  hydrops.  In  the  tertiary  stage  chronic  serous 
synovitis  may  be  present. 

These  and  other  processes  may  be  the  result  of  gummata  of  the  ends 
of  the  bones  or  in  the  periosteum  or  situated  about  the  joints,  not  nec- 
essarily in  any  intimate  connection. 

Gummatous  ostitis  is  a  cause  of  secondary  affections  of  the  joints 
when  situated  in  their  neighborhood.  On  section  the  bone  shows,  most 
often  in  the  periphery,  a  yellowish-gray  focus  of  disease,  in  appearance 
strikingly  like  the  early  stage  of  focal  tuberculosis.     But  from  this  lat- 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    253 

ter  it  may  be  distinguished  by  the  absence  of  any  surrounding  h)-per- 
aemia  or  infiltration,  which  goes  with  tuberculous  disease.  Often,  of 
course,  these  gummata  exist  along  with  much  synovitis  of  a  character- 
istic type,  and  a  much  thickened  and  diseased  periosteum.  Gummata 
in  the  periosteum  appear  as  elastic  swellings,  rich  in  fluid,  poor  in  cell 
elements ;  later  they  degenerate  to  material  like  pus,  and  by  fatty  de- 
generation and  absorption,  to  a  cheese-like  substance  and  scar  tissue, 
and  finally  only  a  thickening  remains. 

Secondarily  to  these  periosteal  and  bone  lesions  come  the  capsular 
and  synovial  thickening  and  the  cartilage  degeneration.' 

Hereditary  syphilis  is  proportionately  more  often  attended  by  joint 
complications  than  is  acquired  syphilis.' 

The  most  characteristic  form  of  joint  disease  in  hereditary  syphilis 
in  children  is  the  osteochondritis  of  Parrot.     This  consists  in  a  broaden- 


FlG.  207. 

Fig.  207. — Ostitis  Syphilitica. 


Fig.  208. 
Fig.  208.— Hyperostosis.     (R.  H.  Fitz.) 


ing  of  the  cartilaginous  layer  of  the  epiphysis  next  to  the  diaphysis, 
with  irregularity  of  the  zone  of  ossification.  At  the  same  time  there 
occur  thickening  of  the  epiphysis  and  a  growth  of  granulation  tissue, 
sometimes  breaking  down  in  the  medullary  cavity.  As  a  result  of  this 
process,  separation  of  the  epiphysis  may  occur  spontaneously  or  as  the 
result  of  some  trauma.  Secondary  synovitis  is  likely  to  accompany 
this  process.  This  may  be  of  any  character  and  is  often  purulent,  and 
the  cartilage  may  degenerate  and  soften.  Suppuration  in  general  is 
less  rare  in  hereditary  than  in  acquired  syphilis. 

The  clinical  symptoms  of  this  osteochondritis  are  thickening  of  bone 
at  the  epiphyseal  line,  tenderness,  and  joint  inflammation,  secondarily 
with  lameness  and  even  uselessness  of  the  limb  for  a  time.     It  may 


'  N.  Y.  Med.  Jour.,  February  4th,  1899. 
-Berl.  klin.  Woch.,  1SS4,  442. — Lancet,  1SS6,  i.,391.- 
p.  294. 


-Deutsch.  Chir. ,  Lief.  66, 


254  ORTHOPEDIC  SURGERY. 

involve  several  joints.  The  affection  is  sometimes  spoken  of  as  syphi- 
litic pseudoparalysis  of  infants. 

Later  hereditary  syphilis  may  show  a  somewhat  similar  affection, 
due  to  overgrowth  of  the  epiphysis  and  spoken  of  as  "  chronic  osteoar- 
thropathy of  hereditary  syphilis"  or  "false  tumor  albus."'  The  thick- 
ened and  deformed  epiphyses  form  a  mass  which  appears  as  a  spindle- 
shaped  swelling  (most  often  at  the  knee).  There  is  typically  no 
muscular  spasm,  although  marked  atrophy  of  the  muscles  is  present. 
Pain  is  generally  absent,  although  rarely  there  ma}'  be  some  tenderness 
and  local  heat.  What  inflammation  of  the  joint  is  present  is  secondary 
and  not  characteristic.  It  is  favorably  affected  by  the  usual  treatment 
for  syphilis.' 

Syphilis  of  the  Spine. — Syphilitic  destruction  of  the  bodies  of  the 
vertebrae  must  be  regarded  as  possible  and  not  unlikely,  but  the  re- 
corded cases  of  this  sort  are  not  in  general  satisfactory  as  proving 
pathologically  that  such  a  condition  has  existed.  The  presence  of 
syphilis  in  a  patient  with  a  knuckle  in  the  back  does  not  prove  that  tu- 
berculosis is  absent  or  that  the  vertebral  destruction  is  of  a  syphilitic 
character. 

The  occurrence  of  gummata  in  the  vertebrae  or  near  them  in  such 
position  as  to  cause  pressure  on  the  cord  must  be  admitted,  also  the 
syphilitic  origin  of  certain  vertebral  exostoses.^ 

The  diagnosis  of  syphihtic  spondylitis  in  most  cases  has  rested  on 
the  slenderest  clinical  evidence,  which  cannot  be  accepted.  The  case 
reported  by  Joachimsthal,"  where  a  cervical  deformity  disappeared 
under  antisyphilitic  treatment,  is  of  interest  in  this  connection.  Under 
these  circumstances  nothing  can  be  said  of  the  clinical  course  of  the 
affection. 

GOUT. 

The  joint  affection,  which  is  the  manifestation  of  the  constitutional 
malady  known  as  gout,  ordinarily  begins  as  an  acute  attack,  and  is  fol- . 
lowed  by  a  chronic  inflammatory  process,  increased  by  constant  exacer- 
bations. The  s}'novial  membrane  first  presents  the  appearances  of 
acute  inflammation ;  the  cartilage  also  shows  a  tendency  to  inflamma- 
torv  degeneration  and  erosion,  and  on  its  free  surface  and  in  its  tissue, 
as  well  as  in  its  capsule  and  periarticular  structures,  there  appears  a 
deposit  of  acicular  crystals  of  urate  of  soda,  which  localized  deposits 

^  Borchard  :  Deutsch.  Zeit.  f.  Chir.,  Ixi.,  no. — Hippell:  Miinch.  med.  Woch., 
xxxi.,  1903. — Palier :  Am.  Med.,  July  iSth,  1902. — Dunn  and  Robinson:  Lancet, 
August  ist,  1903. 

-Charcot:    Comptes  rendus  de   la    Soc.   de  Biol..    1S65.   28. — v.   Becliterew  : " 
Neurol.  Centralbl.,  1893,  313. — Foderl  und  Peham  :    Deutsch.  Zeit.  f.   Chir.,  xlv. 
— Amidon:  N.  Y.  ?kled.  Jour..  1SS7,  225. 

^Zeitsch.  f.  orth.  Chir.,  xi.,  i,  200. 


OTHER  AFFECTIONS  OF  BONES  AND  JOINTS.    255 

are  known  as  "  tophi."  The  marginal  growths  are  true  exostoses 
and  not,  as  in  arthritis  deformans,  covered  by  proliferating  cartilage. 
There  is  a  permanent  thick- 
ening of  the  synovial  mem- 
brane. There  is  but  little 
tendency  to  suppuration,  un- 
less the  calcareous  deposits 
ulcerate  through  the  skin 
by  pressure  and  so  open 
the  periarticular  tissue.  The 
common  seat  of  the  affec- 
tion is  the  metatarsopha- 
langeal joint  of  the  great 
toe  (podagra).  The  joints 
of  the  hands,  and  the  knee- 

and       elbow-joints       are      also        p,^     .og-Knee-joiot    Surfaces    in    Gout,    Showing 

often  affected.  Deposits. 

OSTITIS    DEFORMANS 

Paget's   disease — Osteomalacia    chronica   deformans    hypertrophica — 
Paget'sche  Krankheit. 

These  names  designate  a  deformity  affecting  the  long  bones,  chiefly^ 


Fig.  210. — Photograph  and  Radiograph  of  Case  of  Gout,  Showing  the  Deposits. 

in  their  diaphyses,  and  causing  them  to  bend.  It  most  frequently 
attacks  the  lower  extremities  first,  also  involving  the  spine  and  the 
skull.  The  upper  extremities  are  at  times  curved.  The  process  con- 
sists of  a  thickening  and  curving  of  the  affected  bones,  the  bone  hyper- 


256 


ORTHOPEDIC  SURGERY. 


trophying  as  a  whole  and  its  curves  increasing,  while  the  external  sur- 
face is  roughened.  In  some  cases  the  enlargement  takes  place  by  the 
expansion  of  the  cortex ;  in  other  cases  the  spongy  part  of  the  bone  is  ex- 
tended. The  skull  shows  marked  thickening  and  enlargement,  sometimes 
to  four  or  five  times  its  normal  thickness, 
and  its  surface  is  rough  and  uneven. 


Fig.  211.— Ostitis  Deformans.  Male,  age  fift)'-four.  First  definite  signs  seven  years  before 
photograph.  Present  involvement  most  marked  in  cranium,  clavicles,  right  ulna,  left 
radius,  pelvis,  tibiae,  and  fibias.     (R.  B.  Osgood.) 


Microscopic  examination  shows  appearances  of  absorption  and  new 
formation.  The  first  is  shown  by  the  formation  of  Howship's  lacunae, 
and  where  one  finds  the  formation  of  new  bone  it  is  very  poor  in  lime 
salts.  Later  deposit  of  lime  salts  may  occur  in  this  tissue,  forming 
thick  sclerotic  islands  in  the  osteoid  tissue.  The  marrow  and  vascular 
spaces  are  increased  in  extent  and  the  fatty  part  of  the  marrow  tends  to  be- 
come fibrous.    The  proportion  of  mineral  salts  in  the  bones  is  diminished. 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    257 


Etiology. — In  the  matter  of  etiology  nothing-  definite  has  been  es- 
tabhshed.  The  disease  at- 
tacks men  more  frequently 
than  women,  as  was  found 
in  the  analysis  of  twenty- 
five  ]5ersonal  cases  by  R.  B. 
Osgood  and  W.  A.  Locke, 
of  Boston.'  They  also  found 
that  the  disease  began  at 
an  earlier  period  of  life  than 
was  previously  supposed, 
the  average  of  twenty-one 
cases  showing  the  period  of 
onset  to  be  at  the  age  of 
forty-three  to  forty -four 
years.  It  is  significant  that 
in  the  majority  of  their 
cases,  the  disease  was  as- 
sociated with  marked  ar- 
teriosclerosis. In  five  other 
cases  there  were  manifesta- 
tions of  arthritis  deformans. 
The  relation  of  the  two  dis- 
eases is  obscure,  and  Rich- 
ard asserts  that  pathologic- 
ally they  are  identical." 
This  point  of  view  cannot 
yet  be  regarded  as  estab- 
lished. 

Symptoms . — The  affec- 
tion is  generally  ushered 
in  by  a  long  period  of  pain 
described  as  "  rheumatic  " 
and  by  headaches.^  Some 
cases  are,  however,  practi- 
cally painless.  In  cases  of  in- 
volvement of  the  skull  neu- 
ralgia from  pressure  may  be 
present,  but  the  reflexes  and 
electrical  reactions  remain  normal.  The  general  condition  of  the  patient 
is  often  not  seriously  affected.    The  attitude  is  characteristic,  the  patient 

'  Paper  not  as  yet  published. 

^"Hdbch.  der  orth.  Chir.,"  Joachimsthal,  Jena,  1904,  p.  81. 
^Wallenberg:  Zeitsch.  f.  orth.  Chir..  xiii..  i. 
17 


Fig.  212. — l/ower  Leg-,  Ostitis  Deformans.  Bowing  and 
lamellar  thickening-  of  tibia  and  fibula.  Areas  of 
rarefication  or  true  cavitj-  formation  -^vith  apparent 
periosteal  overgrowth  and  cortical  increase.  Coarse 
trabeculation  and  partial  obliteration  of  medullarj' 
cavity.     ^Marked  arteriosclerosis.     (R.  B.  Osgood.) 


25B 


ORTHOPEDIC  SURGERY. 


stands  with  the  legs  bowed  and  the  spine  bent  in  a  gradual  backward 
curve,  the  body  is  carried  forward  bent  at  the  hips,  and  the  skull  is  greatly- 
enlarged.     The  gait  becomes  clumsy  and  stiff,  the  head  drops  tow- 


FlG.  213. — Ostitis  Deformans.  Marked  involvement  of  left  radius  and  right  ulna.  Character- 
istic coarse  trabeculation  and  lamellar  thickening  with  irregular  periosteal  outline.  Med- 
ullary cavity  obscured  or  obliterated.  Beginning  process  in  proximal  phalanx  of  left 
thumb  and  right  os  magnum.    Arteriosclerosis  of  man}-  vessels.     (R.  B.  Osgood.) 

ard  the  chest,  and  the  shoulders  are  round  and  stooping.  The  spine 
loses  its  flexibility  and  becomes  more  or  less  rigid.  Scoliosis  may  oc- 
cur in  the  spine  of  a  moderate  degree.  The  body  is  shortened  in  the 
erect  position,  and  the  backward  curve  of  the  spine  and  the  attitude 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.     259 

resemble  that  of  spondylitis  deformans.  In  ostitis  deformans,  however, 
the  joints  are  as  a  rule  exempt,  and  the  diagnostic  symptoms  are  the 
occurrence  of  bow-legs  beginning  in  the  latter  half  of  life,  the  bending 
backward  of  the  spine,  the  hypertrophy  of  the  bones,  and  especially  the 
great  thickening  of  the  skull.  Fractures  occur  rarely,  and  in  the  cases 
observed  (Smith,  Taylor,  Kedder,  Bradford)  they  united  readily. 

Prognosis. — The  prognosis  of  the  affection  as  far  as  life  goes  is  not 


Fig.  214.— Charcot's  Disease  of  Right  Knee-joint.     (Weigel.) 

unfavorable,  and  death  generally  occurs  from  intercurrent  affections. 
No  satisfactory  treatment  has  been  formulated.  Protective  apparatus 
in  the  severer  deformities  may  be  necessary,  but  they  increase  muscu- 
lar weakness  and  are  to  be  avoided  if  possible. 

PATHOLOGICAL   CONDITIONS    OF    THE    NERVOUS    SYSTEM. 

Charcot's  joint  disease,  spinal  or  neuropathic  arthropathy,  neural 
arthropathy,  tabetic  arthropathy,  etc. 

A  destructive  form  of  joint  disease  may  be  associated  with  locomo- 
tor ataxia,  syringomyelia.  Pott's  disease,  acute  myelitis,  injuries  of  the 


26o  ORTHOPEDIC  SURGERY. 

peripheral  nerves,  cerebral  apoplexy,  tumors  of  the  cord,  crushing  of 
the  spinal  cord,  progressive  muscular  atrophy,  and  anterior  poliomye- 
litis. 

The  pathological  process  is  in  many  respects  similar  to  that  in  ar- 
thritis deformans,  except  that  the  destructive  process  is  more  rapid  and 
the  formative  activity  less.  The  cartilage  disintegrates,  the  ends  of  the 
bones  are  exposed  and  may  be  rapidly  worn  away,  the  synovial  mem- 
brane and  ligaments  thicken  and  ulcerate.  This  process  may  result  in 
spontaneous  luxation  in  severe  cases.  Synovial  effusion  may  be  pres- 
ent, and  suppuration  may  occur.  Hypertrophy  of  the  epiphyses  may 
take  place  as  well  as  the  formation  of  osteophytes,  but  atrophic  changes 
predominate.  The  essential  character  of  the  affection  is  the  rapid 
melting  away  of  cartilage  and  bones,  and  the  joint  changes  may  be 
present  at  an  early  stage  of  the  nervous  disorder. 

The  affection  is  most  often  monarticular,  and  although  adults  are 
generally  affected,  cases  have  been  recorded  as  early  as  the  sixth  year. 
The  joints  are  affected  in  approximately  the  following  order  of  fre- 
quency: knee,  hip,  shoulder,  tarsus,  elbow,  ankle,  wrist,  jaw,  and 
spine. 

Swelling,  effusion,  disability,  and  sometimes  pain  are  the  first  signs 
of  the  joint  involvement.  Spontaneous  arrest  of  the  process  may  occur, 
and  ankylosis  may  rarely  result.  More  commonly,  however,  the  joint  is 
disorganized  to  the  point  of  luxation.  The  diagnosis  is  often  difficult, 
especially  in  the  early  stages. 

The  treatment  does  not  differ  essentially  from  that  of  inflamed 
joints  in  general.  The  nervous  lesion  must  be  treated,  and  although 
excision  of  the  joint  has  been  successfully  done  under  these  conditions, 
local  operative  measures  are  not,  as  a  rule,  to  be  advised.  In  cases  in 
Avhich  syphilitic  history  is  present,  mercury  or  iodide  of  potassium 
should  be  given. 

Arthropathy  of  the  vertebral  column  has  been  rarely  observed  in 
tabes.  It  is  manifested  by  a  deformed  position  of  the  column,  shown 
by  scoliosis  and  backward  bending  of  the  sphie.'  Partial  relief  may 
be  afforded  by  fixation. 

Arthropathy  of  the  Hip. — In  frequency  of  attack  the  hip  comes  next 
to  the  knee,  which  among  the  large  joints  is  the  one  most  often  affected. 
As  in  most  other  instances,  Charcot's  disease  of  the  hip  simulates  very 
■closely  arthritis  deformans  of  the  ordinary  type.  The  changes  in  the 
joint  are,  however,  much  more  acute  and  extensive  than  those  with 
which  we  are  familiar  in  arthritis  deformans.  Synovial  effusion  is  a 
more  prominent  symptom,  sometimes  reaching  the  stage  of  a  large 
fluctuating  tumor  which  presents  itself  at  the  front  and  the  back  of 

'Spiller:  Am.  Medicine,  November  ist,  1902,  p.  701  (with  bibliography). — 
Graetzer:  Deutsch.  med.  Woch.,  December  24th,  1903. 


OTHER  AFFECTIONS   OF  BONES  AND  JOINTS.    261 


the  joint,  with  a  wearing  away  of  the  head  of  the  bone.  The  trochan- 
ter ascends  and  a  state  of  affairs  similar  to  the  condition  found  in  late 
hip  disease  is  presented.  In  the  matter  of  diagnosis,  of  course  one  de- 
pends upon  the  coexistence  of  symptoms  of  spinal-cord  disease.  As  to 
treatment,  little  can  be  accomplished ;  in  cases  in  which  swelling  is  ex- 
cessive, aspiration  of  the  joint  sac  may  give  temporary  relief.  Rest 
is  indicated  for  the  joint,  with  traction  if 
it  gives  relief. 

H./EMOPHILIA. 

Haemophilia  is  accompanied  at  times 
by  characteristic  joint  lesions,  which  in 
their  clinical  resemblance  to  tuberculosis 
are  worthy  of  notice.'  The  knee  is  the 
joint  most  frequently  affected.  Like 
other  manifestations  of  this  diathesis, 
joint  affections  occur  most  often  in  male 
children  or  young  adults,  decreasing  in 
frequency  with  increasing  age.  The  hem- 
orrhage may  be  intraarticular  or  periar- 
ticular. After  repeated  acute  attacks  of 
hemorrhage  into  the  joint,  chronic  joint 
changes  are  likely  to  ensue.  There  is  an 
overgrowth  of  brown-stained  synovial 
tufts.  The  cartilage  may  degenerate, 
and  sharp-bordered  defects  in  it  are  fre- 
quently found.  Adhesions,  contractions 
of  the  capsule,  and  bony  displacements 
may  occur.  Erosion  of  the  ends  of  the 
bones  may  take  place  along  with  a  pro- 
liferation at  the  edges  not  unlike  arthritis 
deformans.  A  brown  staining  of  all  the 
joint  structures,  except  the  cartilage,  is 
described  as  characteristic. 

Rheumatic  pains  are  a  common  clinical  accompaniment  of  the  affec- 
tion, and  its  character  is  essentially  chronic.  Swelling  and  muscular 
spasm  are  present  during  attacks  of  irritation,  and  the  diagnosis  from 
tuberculosis  is  to  be  made  more  from  the  history  than  from  any  char- 
acteristic features.' 


Fig.  215. —Disease  of  liight  Knee- 
joint  of  Six  Years'  Duration  Due 
to  Hsemophilia,  Showing  Swell- 
ing and  Flexion  Defonnit}'. 


'Am.  Medicine,  March  21st,  1903,  editorial.  — Carless  (with  analysis  of  253  re- 
ported cases):  Practitioner,  1903,  Ixx.,  85. 

-Linser:  Bruns'  Beitr.  zur  klin.  Ch.,  Bd.  xvii.,  105. — \'olkmann"s  Samml. 
klin.  Vortrage  (Transl.  Med.  Surg.  Reporter,  Ixvi.,  Xo.  26.  p.  999). — Gocht: 
Mi.inch.  med.  Woch.,  1899,  February  21st,  271. 


262 


ORTHOPEDIC  SURGERY. 


General  treatment  offers  but  little  hope,  although  the  use  of  gelatin 
by  mouth,  in  doses  of  six  or  more  ounces  daily,  has  been  found  of  use.' 


Fig.  216.— Clubbing  of  Fingers  in  Secondarj-  Osteo-arthropathy. 

Protection  to  the  diseased  joints  is  of  more  use  than  any  other  one 
measure,  but  the  prognosis  as  to  recovery  is  doubtful  at  best.  Aspira- 
tion with  a  small  needle  may  be  safely  done  for  purposes  of  diagnosis,^ 


Fig.  217.— Secondary  Osteo-arthropathy  Due  to   Pott's  Disease,  Showing  Enlargement   of 

Liver  and  Spleen. 


these 


Fatal  hemorrhages  have  occurred  as  the  result  of  operation  on 
supposedly  tuberculous  joints. 

'  Hesse:  Ther.  der  Gegenwart,  September,  1902  ;  Practitioner,  1903,  Ixx.,  85. 
-  For  normal  processes  of  absorption  of  blood  in  joints  see  Jaffe :  Langen 
beck's  Archiv,  Bd.  liv.,  Hft.  i. 


OTHER  AFFECTIONS    OF  BONES  AND   JOINTS.    263 

SCURVY. 

Joint  affections  in  infantile  scurvy  are  not  uncommon,  and  simu- 
late closely  epiphysitis.  The  enlargement  may  be  confined  to  one  of 
the  bones  forming  an  articulation.  The  thickening  is  due  to  periarticu- 
lar or  rather  subperiosteal  hemorrhage,  and  the  joint  itself  is  not  usu- 
ally affected,,  though  hemorrhage  may  occur.  Such  joints  yield  readily 
to  the  usual  treatment  of  infantile  scurvy.  Such  apparent  inflammation 
of  joints  occurring  in  scurvy  is  regarded  as  being  more  often  due  to 
extraarticular  than  to  intraarticular  lesions,  subperiosteal  hemorrhage 
being  the  most  frequent  lesion.  In  379  cases  of  scurvy  investigated  by 
the  American  Pediatric  Society  '  there  were  swellings  in,  or  more  often 
about,  the  joints  in  165.  These  were  distributed  as  follows:  Knee,  T},; 
ankle,  28;  wrist,  12;  hip,  6;  shoulder,  5;  elbow,  3;  hand,    i. 

In  40  analyzed  with  regard  to  the  coexistence  of  rickets,  in  45  per 
cent  there  were  symptoms  of  rickets,  while  in  55  per  cent  rickets  was 
said  to  be  definitely  absent. 

SECONDARY   HYPERTROPHIC    OSTEO-ARTHROPATHY. 

This  is  the  name  given  to  a  condition  occurring  sometimes  in  con- 
nection with  chronic  pulmonary  disease,  in  which  the  fingers  are  clubbed 
and  stiffened,  the  shafts  of  the  bones  are  thickened,  and  the  spine  is 
bent  forward  in  a  kyphosis.  It  occurs  sometimes  in  connection  with 
Pott's  disease.  The  relation  of  the  affection  to  acromegaly  and  osteo- 
malacia is  not  clear. 

In  this  condition  the  joints  are  occasionally  swollen  and  painful  with 
effusion.  The  changes  as  shown  by  autopsy  *  are  synovitis  and  thinning 
of  the  articular  cartilages  even  to  the  extent  of  exposing  the  bone. 
Along  with  this  is  associated  periostitis  and  some  sclerosis  of  bone 
which  may  involve  the  shaft. 

GROWING   PAINS. 

A  joint  affection  incident  to  growth  has  been  described  by  Bouilly, 
and  has  long  been  known  but  unclassified  by  practitioners,  and  popu- 
larly considered  to  be  incident  to  growth^ — "growing  pains."  There  is 
slight  pain  chiefly  in  the  juxtaepiphyseal  region,  most  commonly  near 
the  lower  epiphysis  of  the  femur.  This  pain  is  brought  on  by  fatigue, 
strains,  or  exposure.  In  the  lightest  cases  the  symptoms  pass  away  in 
a  few  hours.  In  severer  forms  they  may  last  for  several  days,  and  the 
pain  may  be  accompanied  by  slight  fever.     In  the  severest  form  the 

'  Boston  Med.  and  Surg.  Jour.,  vol.  cxxxviii.,  607. 

■■^  Lefebre  :  These  de  Paris,  1S91. — Ranzier:  Rev.  de  Med.,  1891,  p.  30. — Whit- 
man: Pediatrics,  1899,  vii.,  Nos.  4  and  5  (with  bibhography).— Janeway  :  Am. 
Joum.  Med.  Sci.,  October,  1903  (with  bibliography). 


264 


ORTHOPEDIC  SURGERY. 


affection  may  continue  for  months.  There  may  be  slight  effusion  in 
the  joints,  but  recovery  eventually  takes  place.  It  may  occur  during 
the  ages  between  five  and  twenty -one. 

A  great  amount  of  harm  is  done  in  referring  to  this  class  the  pains 
of  beginning  chronic  joint  disease.  Growing  pains  proper  are  neither 
severe  nor  permanent. 

Analogous  to  this  may  be  mentioned  what  has  been  termed  by 
French  writers  maladie  de  la  croissance — which  is  in  reality  a  hyper- 
aemia  and  sensitiveness  of  the  epiphysis  in  adolescents — analogous  to 
what  is  seen  occasionally  in  rickets. 

ACTINOMYCOSIS. 

Actinomycosis  is  a  specific  infectious  disease  occasionally  attacking 
the  bone  secondarily,  and  is  caused  by  the  streptothrix  actinomycotica 
(ray  fungus).     The  process  in  the  bone  is  a  destructive  one. 


Fig.  218. — M3'ositis  Ossificans.     (Michelson.) 

The  spinal  column,  ribs,  and  sternum  may  be  attacked,  but  the 
maxilla  is  the  bone  most  frequently  affected,  and  the  whole  affection 
is  to  be  regarded  as  one  attacking  the  soft  parts,  the  involvement  of 
bone  being  only  secondary  and  incidental.  The  source  of  the  infection 
is  through  the  gastrointestinal  or  respiratory  tract,  and  the  persons 
commonly  affected  are  those  who  live  in  the  country  and  handle  grain.' 

Actinomycosis  of  the  spine  is  rare,  but  few  cases  having  been  re- 

'  Ruhrah  :  Annals  of  Surgery,  vol.  x.xx..  p.  417. — Von  Braez  :  Annals  of  Sur- 
gery, vol.  xxxvii.,  p.  337.— Acland:  Lancet,  1SS6,  p.  973. 


OTHER    AFFECTIONS   OF  BONES  AND  JOINTS.    265 

ported.  It  may  be  destructive,  resembling  Pott's  disease.  In  a  case 
seen  by  one  of  the  writers,  in  which  the  upper  dorsal  region  was  affected^ 
there  was  an  extensive  induration  of  the  neck  and  shoulders  and  the 
skin  was  riddled  by  sinuses.  The  constitutional  disturbance  was  very 
marked,  as  shown  by  anaemia  and  prostration.  The  early  symptoms 
had  been  similar  to  those  of  Pott's  disease,  and  there  was  flattening  of 
the  back  of  the  neck.  The  diagnosis  was  made  by  microscopic  exami- 
nation of  the  discharge  from  the  sinuses. 

The  treatment  consists  in  the  administration  of  iodide  of  potassium. 

In  the  writers'  case  progressive  improvement  in  symptoms  follow^ed 
the  use  of  this  drug. 

EchinococciLS  cysts  of  the  spine  have  been  observed.' 

MYOSITIS   OSSIFICANS. 

This  affection  in  its  symptoms  is  closely  enough  allied  to  those 
caused  by  certain  joint  diseases  to  recjuire  mention.     The  pathology  of 


Fig.  219.— Radiograxjh  of  vSame  Case  Showing  Irregular  Deposits  of  Bone.     (Michelson.) 

the  disease  consists  of  the  formation  of  bone  tissue  in  the  connective 
tissue  surrounding  the  muscles.  This  is  of  the  periosteal  type  and 
occurs  in  plates  or  irregular  shapes.  The  affection  is  one  largely  af- 
fecting children  and  its  cause  is  unknowii.  Trauma  is  a  cause  of  many 
cases,  and  at  times  the  disease  is  progressive,  attacking  one  muscle 
after  another.  The  affection  is  most  commonly  found  in  the  forearm, 
leg,  or  thigh,  but  any  muscle  may  be  involved. 

'Friedberg:  Schmidt's  Jahrb..  1S97. — Bruns' Beitr..  xi.,  1S94. 


266  ORTHOPEDIC  SURGERY. 

The  affection  is  manifested  clinically  by  the  appearance  of  tumors 
involving  the  muscle,  which  may  or  may  not  be  painful.  Fever  may 
be  present  or  absent.  The  muscles  involved  are  stiffened  and  may  be- 
come useless,  while  at  other  times  but  little  inconvenience  is  felt. 

No  satisfactory  treatment  has  been  formulated  and  no  measure  has 
been  found  to  control  the  disease.     The  tumors  may  be  excised.' 

ANKYLOSIS. 

Ankylosis  is  the  name  used  to  characterize  the  persistent  stiffness 
of  a  joint.  This  may  be  "  complete  "  when  all  motion  is  lost,  or  "  par- 
tial "  or  "incomplete"  when  some  part  of  the  normal  motion  remains. 
It  is  also  classified  as  "  bony  "  or  "  fibrous  "  ankylosis,  according  to  the 
character  of  the  tissue  binding  together  the  joint  surfaces.  False  an- 
kylosis, pseudo-ankylosis,  etc.,  are  terms  used  to  designate  a  condition 
of  joint  stiffness  in  which  the  restriction  of  joint  motion  is  due,  not  to 
destruction  of  the  joint  surfaces,  but  to  other  causes,  such,  for  example, 
as  the  development  of  osteophytes  and  the  like  around  the  edges  of  the 
joint  occurring  in  arthritis  deformans,  the  contraction  of  the  joint  cap- 
sule, etc. 

The  name  ankylosis  should  not  be  applied  to  the  stiffness  of  joints 
due  to  the  tonic  muscular  spasm  of  acute  or  chronic  joint  disease.  This 
disappears  under  anaesthesia,  whereas  ankylosis  is  not  affected  by  it. 

The  pathology  of  ankylosis  is  the  pathology  of  the  affections  which 
cause  it.  It  represents  in  general  the  end  result,  the  cicatrix,  of  an 
acute  or  chronic  joint  inflammation  or  of  a  more  or  less  severe  trauma. 
True  ankylosis  in  all  cases  consists  of  the  formation  of  fibrous  tissue 
connecting  the  ends  of  the  joint,  which  later  is  apt  to  undergo  bony 
transformation.  The  cartilage,  if  not  originally  destroyed  by  the  dis- 
ease, degenerates  from  disuse,  and  in  the  severer  cases  the  entire  ends 
of  the  bones  are  connected  by  fibrous  bands,  and  later  by  a  solid  mass 
of  bone.  In  such  cases  the  cortical  parts  of  the  ends  of  the  bones 
forming  the  joint  may  be  absorbed  and  the  medullary  cavity  may  extend 
uninterrupted  from  the  leg  to  the  thigh,  for  example.  In  such  cases 
the  joint  is  wholly  obliterated,  and  the  leg  and  thigh  form  one  continu- 
ous bone. 

Stiffness  of  joints  may  also  result  from  adhesions  between  the  syn- 
ovial membrane,  from  contraction  of  the  capsule  and  ligaments,  from 
adhesions  between  the  tendons  and  their  sheaths,  from  periarticular 
cicatrices  due  to  abscesses  and  trauma,  from  marginal  ecchondroses  and 
exostoses,  from  the  ensheathing  formation  of  new  bone,  the  alteration  of 
joint  surfaces  in  arthritis  deformans,  and  from  fractures  and  dislocations. 

'  Binine  :  Annals  of  Surgery,  1903  (report  of  ^(i  cases). — C.  Rothschild  :  Beitr. 
z.  klin.  Chir.,  xxviii.,  i. — Michelson:  Zeitsch.  f.  orth.  Chir.,  xii.,  3  (with  bibliog- 
raphy). 


OTHER   AFFECTIONS    OF  BONES  AND  JOINTS.    267 

The  causes  of  acquired  ankylosis  are  therefore  to  be  found  in  acute 
or  chronic  joint  inflammation,  in  the  ankylosing  form  of  arthritis  de- 
formans, in  fractures  involving-  the  joints,  in  trauma  of  various  kinds, 
and  in  periarticular  suppuration  and  trauma.  The  fixation  of  normal 
joints  for  any  reasonable  time  does  not  cause  true  ankylosis.' 

Ankylosis  may  occasionally  occur  as  a  congenital  condition. 

The  joint  may  be  stiffened  in  any  part  of  its  normal  arc  of  motion. 
Ankylosis  is  more  common  in  a  deformed  than  in  a  straight  position, 


» "'                      J 

HjjPl 

'^In^M  'Vliflii 

^. 

Tr^li^^^ 

^B 

l^^l 

Fig.  220.— Pseudo-ankylosis  of  Hip-joint  Due  to  Arthritis  Deformans.     (Joachimsthal.) 

when  it  is  the  result  of  chronic  joint  diseases.  The  position  in  which 
it  occurs  is  of  great  importance,  as  the  usefulness  of  a  limb  in  cases  of 
irremediable  ankylosis  will  depend  on  stiffness  in  a  useful  position. 

In  the  hip  ankylosis  is  likely  to  occur  in  flexion  and  adduction. 
The  desirable  position  for  ankylosis  of  the  hip  is  in  a  few  degrees  of 
flexion  with  no  adduction  or  abduction. 

In  the  knee  ankylosis  generally  occurs  with  flexion  of  the  leg  with  sub- 
luxation of  the  tibia.     The  useful  position  is  with  the  leg  nearly  straight. 

'  Reyher :  Deutsch.  Zeit.  f.  Chir.,  iii.,  1S73. 


268 


ORTHOPEDIC  SURGERY. 


In  the  ankle  the  desirable  position  for  a  stiff  joint  is  with  the  foot 
at  a  right  angle  to  the  leg. 

In  the  shoulder  the  arm  is  most  useful  if  slightly  abducted  and  a 
little  flexed. 

With  a  stiff  elbow  the  only  useful  arm  is  obtained  with  the  forearm 
at  a  right  angle  to  the  arm. 

The  diagnosis  of  ankylosis  is  made  by  the  absence  or  limitation  of 
motion.     It  is  not  diminished  by  anaesthesia,  and  the  x-ray  shows  the 


Fig.  221.— True  Ankylosis  of  Hip-joint  Due  to  Tuberculous  Disease.     (Warren  Museum.) 


disappearance  of  the  line  between  the  bones  and  the  continuity  of  bony 
structure  in  bony  ankylosis. 

The  prevention  of  ankylosis  consists  in  the  efficient  treatment  of 
the  affections  likely  to  cause  it. 

The  treatment  of  ankylosis  when  the  union  is  not  bon)-  naturally 
differs  from  that  when  the  ends  of  the  joint  are  connected  by  bone.  In 
the  latter  case  non-operative  treatment  is  useless. 

In  incomplete  ankylosis  an  attempt  may  be  made  to  stretch  the 
connecting  structures  and  thus  increase  the  amount  of  motion. 

Manual  Stretching. — This  may  be  done  by  gradual  manual  stretch- 
ing, in  which  gentle  manipulative  force  is  used  at  short  intervals  and 
repeated  daily.     If  too  much  force  is  used,  inflammatory  reaction  will  be 


OTHER   AFFECTIONS    OF  BONES  AND   JOINTS.    269 

started  in  the  joint,  and  the  condition  will  be  made  worse.  The  use  of 
a  proper  degree  of  force  should  be  followed  by  a  daily  increase  of  joint 
motion  without  great  pain. 

Mechanical  Correction.- — The  attempt  at  stretching  ma}'  be  made  by 
means  of  2^ pcndnliivi  apparatus,  in  which  a  carefully  controlled  rh)-th- 
mical  movement  is  exerted  to  any  desired  e.xtent.  The  Zander  appa- 
ratus may  be  used  in  a  similar  way  to  increase  the  range  of  joint  motion. 

Local  Mcasnirs. —  Certain  measures  affecting  the  local  circulation 
seem  to  aid  in  restoring  flexibility  in  connection  with  the  stretching 
mentioned  above.  These  are  Bier's  congestive  method,  hot-air  baths, 
massage,  and  vibrator)^  massage. 

This  treatment  is  suited  to  the  stiffness  following  fractures  and 
joint  injuries,  the  loss  of  motion  in  arthritis  deformans,  and  after  non- 
tuberculous  inflammations  in  and  around  the  joints. 

Forcible  StretcJiing. — In  case  these  measures  prove  ineffectual  the 
patient  should  be  anaesthetized  and  the  arc  of  motion  of  the  stiffened 
joint  increased  by  the  use  of  moderate  force  to  stretch  or  break  the 
adhesions  existing.  This  should  be  followed  by  rest  to  the  joint  for 
one  or  two  days,  followed  by  the  resumption  of  the  gentle  measures 
described.  The  injudicious  use  of  force,  as  a  rule,  does  more  harm  than 
good  by  exciting  inilammation  and  causing  new  adhesions.  After  the 
use  of  manipulative  force  the  joint  should  be  fixed  in  the  position  of 
greatest  usefulness,  described  above. 

In  the  case  of  bony  ankylosis  these  measures  are  of  no  value. 

If  the  ankylosis  has  occurred  in  a  position  of  deformity,  the  joint 
should  be  corrected  and  the  limb  placed  in  a  useful  position  by  osteot- 
omy or  excision. 

Osteotomy  is,  as  a  rule,  linear,  and  is  generally  performed  just  above 
or  below  the  joint  surface.  Wedge-shaped  osteotomy  inevitably  short- 
ens a  limb,  but  may  be  required  in  cases  of  extreme  deformity. 

Excision  may  be  done  at  the  site  of  an  ankylosed  joint,  not  with  a 
view  of  restoring  motion,  but  to  correct  deformity.  The  planes  of  the 
resected  ends  of  the  bones  should  be  so  placed  as  to  give  the  desired 
position  of  the  joint  after  union. 

The  application  of  these  methods  to  the  especial  joints  has  been 
discussed  in  connection  with  each  joint. 

Formation  of  New  Joints. — In  bony  ankylosis  the  formation  of  a 
new  joint  at  the  site  of  the  former  one  may  be  attempted.  The  method 
of  interposing  a  layer  of  fascia  or  other  foreign  substance  between  the 
resected  ends  of  the  bone  in  cases  of  true  bony  ankylosis  has  been 
described  and  successfully  carried  out  with  marked  success,  especially 
by  Murphy,'  of  Chicago.  The  hope  of  success  in  the  operation  depends 
upon  the  fact  that  aponeurosis  attached  to  fatty  tissue  when  subject  to 
'  ^Murphy  :  Trans.  Am.  Surg.  Assn.,  x.xii  ,  315  (with  literature). 


270  ORTHOPEDIC  SURGERY. 

pressure  tends  to  form  an  hygroma  or  bursa.  If,  then,  the  line  of  union 
where  the  joint  formerly  existed  is  chiselled  or  cut  through  in  approxi- 
mately the  original  joint  plane,  and  aponeurotic,  or  muscular,  and  fatty 
tissue  is  interposed,  there  is  hope  of  a  restoration  of  joint  motion  in 
place  of  the  former  bony  ankylosis.  The  capsule  and  synovial  mem- 
brane, if  the  latter  remains,  are  extirpated  and  only  essential  bands  of 
ligaments  are  left.  Bony  outgrowths  are  removed,  adherent  tendons 
freed,  cicatricial  contractions  cut  out,  and  a  flap  of  the  desired  tissue  is 
taken  from  the  neighborhood  and  turned  in  between  the  ends  of  the 
bones.  This  flap  should  be  secured  to  the  edges  of  the  capsule  and  is 
left  attached  by  its  base.  Use  of  the  limb  is  at  first  painful,  and  passive 
motion  under  anaesthesia  may  be  required.  Murphy  reports  a  series  of 
successful  cases  in  various  joints.  The  causes  of  failure  he  enumerates 
as  follows : 

1.  Insufficient  or  defective  exsection  of  synovial  membrane,  cap- 
sule, and  ligaments. 

2.  Insufihcient  interposition  of  fat  and  aponeurosis  or  muscle  be- 
tween the  separated  bony  surfaces. 

3.  Infection. 

4.  Sensitiveness  to  pain  in  motion  after  operation 


CHAPTER    IX. 
RICKETS,    KNOCK-KNEE,    AND    BOW-LEGS. 

Rickets.— Definition.— Pathology.  — Occurrence  and  Etiology.— Symptoms.— Di- 
agnosis.— Prognosis. — Treatment. 

Osteomalacia. — Chondrodystrophia  foe  talis — Foetal  rickets. 

Knock-knee.— Occurrence  and  etiology. — Symptoms. — Diagnosis. ^ — Treatment. — 
Expectant. — Mechanical. — Operative. 

Bow-legs.  —  Occurrence.  —  Causation.  —  Symptoms.  —  Diagnosis.  —  Prognosis. — 
Treatment. — Expectant. — Mechanical. — ^  Operative. 

Rhachitic  curves  in  the  upper  extremity. — Improperly  united  fractures. 

RICKETS. 

Definition. — Rickets  is  a  constitutional  disease  which  affects  young 
children.  Its  chief  characteristics  are  manifested  in  the  osseous  sys- 
tem, where  there  is  a  local  or  general  disturbance  of  the  normal  proc- 
ess of  ossification,  as  a  result  of  which  the  epiphyses  become  enlarged 
and  the  affected  bones  become  soft  and  pliable ;  growth  is  delayed  and 
deformities  of  a  serious  character  arise.  The  affection  itself  does  not 
belong  to  the  category  of  surgical  diseases ;  but  the  resulting  deformi- 
ties demand  strictly  surgical  treatment,  and  it  is  important  that  the  sur- 
geon should  familiarize  himself  with  the  leading  features  of  the  affec- 
tion. 

The  disease  is  known  in  English  as  rickets  or  rhachitis.  Other 
names  for  the  affection  are:  morbus  anglicus,  articuli  duplicati,  eng- 
lische  Krankheit,  Zwiewuchs,  doppelte  Glieder,  nouure,  rachitisme,  etc. 

Pathology. — Rickets  occurs  especially  at  the  time  when  the  bone 
growth  is  at  its  maximum,  and  its  most  obvious  feature  is  a  defective 
calcification  of  the  bones,  in  consequence  of  which  secondary  changes 
occur. 

In  rickets  the  pathological  changes  are  most  marked  at  the  junction 
of  the  epiphysis  and  the  shaft.  The  epiphyseal  cartilage,  which  should 
normally  be  a  thin  layer,  in  rickets  appears  as  a  broad,  reddish-gray, 
translucent  cushion,  while  the  whole  epiphysis  is  enlarged. 

The  line  of  calcification  is  thin  or  may  be  wanting  in  places,  the  for- 
mation of  medullary  spaces  extends  into  the  zone  of  calcification  and 
possibly  through  it,  and  the  deposit  of  bone  inside  these  spaces  is  want- 
ing or  irregular,  its  place  being  taken  by  "  osteoid  tissue." 

The  periosteum  of  the  shaft  is  hypersemic  and  thickened  and  boggy 
and  often  adherent  to  the  bone.     The  subperiosteal  layer,  which  nor- 


272 


ORTHOPEDIC  SURGERY. 


mally  is  thin  and  scarcely  noticeable,  in  rickets  is  thick  and  appears 
dark  and  like  spleen  pulp. 

The  medullary  bone  is  more  hyperasmic  than  normal  medulla  at  this 
age.  The  intercellular  substance  may  show  mucoid  degeneration  or  be 
fluid.     It  does  not  seem  that  lime  is  dissolved  out  of  the  finished  bone, 

but  that  resorption  of 
such  bone  in  toto  is  the 
important  element.  Aft- 
er the  active  process  has 
ceased  lime  is  deposited 
in  the  "osteoid  tissue," 
and  the  result  is  a  thick 
and  heavy  bone. 

The  chemical  analysis 
of  rhachitic  bone  shows  a 
percentage  of  nineteen  to 
fifty-three  per  cent  of  ash. 
Ossification  after  the 
process  is  over  becomes 
excessive  and  may  be 
spoken  of  as  petrifaction 
or  eburnation,  rather  than 
true  ossification.  Infrac- 
tions or  partial  fractures, 
with  the  break  on  the 
concave  side  of  the  long 
bones,  may  occur.  The 
ligaments  become  re- 
laxed and  stretched,  and 
the  muscles  flabby  from 
disuse.  The  spleen  is 
ordinarily  enlarged  and 
sometimes  the  liver.  Ca- 
tarrh of  the  alimentary  ca- 
nal and  bronchi  are  com- 
mon accompaniments. 
In  rickets  of  the  skull  the  meninges  and  brain  may  be  secondarily 
affected. 

Occurrence  and  Etiology. — Rickets  is  an  affection  occurring  com- 
monly during  the  first  dentition.  Cases  of  rickets  are,  however,  de- 
scribed as  congenital  and  others  as  occurring  during  adolescence. 

Congenital  Tickets,  or  foetal  rickets,  will  be  discussed  under  the  head- 
ing of  cJiondodystrophici  fcetalis . 

Rickets  in  Childhood. — The  common  time  of  occurrence  is  in  early 


Fig.  222  —Skeleton  in  Rickets.     (Warren  Museum.) 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS.  273 

childhood,  especially  in  the  first  two  years  of  life.  In  a  series  of  400 
medical  out-patients  consecutively  investigated  at  the  Infants'  Hospital, 
Boston,  318  showed  signs  of  rickets,  and  in  106  of  these  the  children 
were  in  their  first  six  months,  134  between  six  and  twelve  months,  and 
the  remainder  between  one  and  two  years.' 

TJic  rickets  of  adolescence  or  late  rickets  is  a  disease  which  affects 
persons  at  about  the  age  of  puberty ; '  it  may  be '  associated  with  albu- 
minuria, and  its  etiological  relations  are  decidedly  obscure.  The  physi- 
cal signs  are  the  same  as  in  the  rickets  of  early  life,  except  that  the 
epiphyseal  enlargement  is  generally  not  so  great.  In  several  cases 
reported  dissection  of  the  skeleton  showed  the  same  characters  as  in 
early  rickets.'' 

In  2,595  cases  of  rickets  reported  from  various  authors,  there  were 
1,337  boys  to  1,258  girls. 

Causation. — Rickets  is  an  affection  of  faulty  nutrition.  It  is  much 
more  prevalent  among  the  crowded  poor  of  the  cities  than  in  rural  com- 
munities, and  certain  races  seem  to  be  more  subject  to  the  affection 
than  others.  The  children  of  the  negro,  Italian,  and  Portuguese  poor 
are  more  frequently  afflicted  than  the  Irish  in  our  Atlantic  American 
cities. 

As  might  be  expected,  the  later  children  of  a  large  family  are  much 
more  liable  to  rickets  than  their  older  brothers  and  sisters. 

Inasmuch  as  rickets  is  a  disease  of  malnutrition,  the  commonest 
causes  are  to  be  sought  in  the  immediate  surroundings  of  the  patient. 

Bad  hygienic  influences,  such  as  poor  ventilation  and  food,  damp 
dwellings,  crowded  rooms,  etc.,  have  a  very  marked  influence  in  pro- 
ducing rickets. 

The  most  evident  cause  other  than  bad  environment  is  faulty  feed- 
ing. The  disease  is  much  less  common  in  breast-fed  than  in  bottle-fed 
children.  In  the  latter,  even  if  carefully  nurtured,  slight  evidence  of 
rickets  is  not  infrequently  seen  in  late  dentition  or  enlarged  epiphyses, 
and  occasionally  in  slight  curves  in  the  long  bones. 

As  to  the  theories  of  the  causation  of  rickets,  the  reader  is  referred 
to  books  on  the  diseases  of  children. 

Artificial  farinaceous  foods  contain  a  very  much  smaller  percentage 
of  fat  than  milk  does,  and  the  experience  at  the  London  Zoological 
Gardens  lends  much  weight  to  the  idea  that  the  deprivation  of  fat  and 

'J.  L.  Morse:  Journ.  Am.  Med.  Assn.,  March  24th,  1900. 

-  Lucas  :  Lancet,  June  9th,  1SS3. 

^  Keetly :  Annals  of  Surgery. — Palm:  Practitioner,  xlv.,  1S90,  p.  275.— Du- 
play  :  Gaz.  des  H6p.,  1S91,  p.  1397.— Robert  Jones:  Brit.  Med.  Journ.,  1896,  i., 
341- 

''Moxon:  Guy's  Hospital  Reports,  187S.— St.  Thomas"  Hospital  Reports, 
vol.  xiv. 

18 


2/4  ORTHOPEDIC  SURGERY. 

proteids  from  the  diet  of  young  animals  is  a  most  important  factor  m 
the  production  of  rickets.  In  menageries,  where  animals  live  under 
highly  artificial  conditions,  rickets  attacks  young  lions  especially,  and  is 
the  cause  of  death  in  a  large  number  of  cases.  Ostriches,  pheasants, 
and  poultry  under  the  same  conditions  have  a  softened  condition  of  the 
bones. 

The  subject  of  the  relation  of  syphilis  to  rickets  must  be  passed  over 
very  briefly,  as  having  only  an  incidental  interest  in  this  treatise.  The 
present  view  rather  regards  syphilis  as  an  indirect  cause  of  rickets  in 
impairing  the  general  constitution.  The  common  experience  is  to  find 
a  small  proportionof  syphilitics  among  rhachitic  children. 

Chronic  tuberculosis  in  the  parents,  as  well  as  debility  from  any 
cause  impairing  the  nutrition,  may  be  the  cause  of  rickets.  Any  ex- 
hausting disease  in  the  child  may  be  followed  by  rickets,  while  bronchi- 
tis is  too  common  a  symptom  of  rickets  to  be  considered  its  cause,  as 
some  writers  would  do.  Finally,  in  certain  rare  cases  no  cause  can  be 
assigned  for  the  occurrence  of  the  affection. 

Symptoms. — The  disease  is  so  often  the  outcome  of  a  long  period  of 
ill-health  that  it  is  difficult  to  say  when  the  rhachitic  symptoms  begin. 
Among  the  commonest  early  symptoms  are  restlessness  at  night,  pro- 
fuse sweating,  especially  of  the  head,  and  constipation  perhaps  alternat- 
ing with  diarrhoea,  but  the  diagnosis  cannot  be  made  from  the  premon- 
itory symptoms. 

The  belly  becomes  large  and  distended  with  symptoms  of  imperfect 
digestion  and  faulty  assimilation.  In  the  severer  cases  the  child  may 
suffer  great  pain  on  being  moved. 

The  so-called  "  paralysis  of  rickets  "  is  at  times  an  accompaniment, 
of  this  stage,  and  is  generally  brought  to  the  parent's  notice  by  the 
child's  inability  to  use  the  limbs.  The  thighs  and  upper  arms  are  the 
regions  most  commonly  affected.  There  is  no  lesion  of  the  nervous 
system  in  these  cases,  and  a  careful  examination  in  the  recumbent  posi- 
tion shows  that  the  child's  muscular  movements  are  impaired  from  the 
pain  caused  by  movement.  The  disability  is  to  be  attributed  to  the 
muscular  weakness  and  the  bone  tenderness,  particularly  to  a  periosteal 
tenderness  at  the  muscular  insertions.  The  electrical  reaction  is  nor- 
mal and  the  reflexes  are  not  affected.  This  pseudo-paralysis  is  an  early 
symptom  of  rickets,  and  as  a  rule  precedes  any  marked  osseous  change, 
which  adds  to  the  difficulty  of  its  recognition.  The  most  difficult  affec- 
tion from  which  to  distinguish  it  is  the  disability  due  to  simple  weak- 
ness in  non-rhachitic  children. 

Fever  is  most  often  absent  or  due  to  some  complication,  such  as 
bronchitis.  Convulsions  may  occur  at  any  stage  of  the  disease,  espe- 
cially when  there  is  any  tendency  to  craniotabes. 

CJimiges  in  the  Bones. — Enlargement   of    the    epiphyses  appears, 


RICKETS.    KNOCK-KNEE,    AND  BOW-LEGS. 


75 


especially  at  the  wrists  and  anterior  ends  of  the  ribs.  Enlargement  of 
the  lower  end  of  the  radius  and  ulna  is  practically  universal,  whereas 
enlargement  of  the  lower  end  of  the  tibia  and  fibula  is  less  frccjucnt. 
These  enlargements  do  not  involve  the  joints.  At  the  ribs  one  finds 
the  "rosary,"  a  series  of  bead-like  enlargements  easily  felt  at  the  junc- 
tion of  the  cartilages  and  the  ribs,  and  a  small  degree  of  epiphyseal  en- 
largement is  easily  detected  here,  and  not  likely  to  be  mistaken  for 
anything  else.  When  these  changes 
have  occurred,  the  bones  have  al- 
ready softened  and  curvatures  of  the 
long  bones  may  have  begun.  In  the 
deep-seated  epiphyses,  like  the  hip 
and  shoulder,  one  does  not  notice 
the  change. 

The  forces  that  work  to  produce 
deformity  in  the  softened  bones  are 
muscular  action,  gravity,  pressure 
from  weight,  atmospheric  resistance, 
and  the  pressure  exerted  on  bony 
structures  by  growing  organs. 

The  typical  Jiead  of  rickets  has 
a  high,  square,  prow-shaped  fore- 
head, with  a  decided  prominence  of 
the  lateral  parts  of  the  frontal  bones 
(frontal  eminences)  and  sometimes 
the  parietal  eminences  as  well. 

The  anterioi'-  fontanel,  which 
should  normally  close  at  about  the 
eighteenth  month,  remains  widely 
open  and  does  not  ossify  until  per- 
haps the  third  year  or  even  later 
This,  however,  is  not  enough  to 
establish  the  fact  that  the  child  is 
rhachitic  until  the  age  of  two  years  has  been  reached, 
fontanel  sometimes  remains  open  for  months. 

The  name  craniotabes  is  applied  to  an  abnormal  thinness  of  portions 
of  the  parietal  and  occipital  bones. 

Hypersemia  of  the  brain  and  meninges  may  be  an  accompaniment. 
With  this  hyperaemia  comes  the  likelihood  of  hydrocephalus,  either  ex- 
ternal or  internal,  and  the  accompanying  cerebral  changes,  so  that  hy- 
drocephalus becomes  a  complication  of  rickets  which  is  not  very  rare. 

Deformities  of  the  chest  "SiXQ.  among  the  most  common  produced  by 
rickets  and  they  occasionally  exist  without  any  well-marked  signs  of 
rickets  elsewhere.     It  is  not  unusual  to  see  young  girls  about  the  age 


FiG"  223.  — Case  of  Rickets  Showing  De- 
formity of  Chest  and  Enlarged  Abdo- 
men.    (J.  .S.  Stone.) 


The  posterior 


276  ORTHOPEDIC  SURGERY. 

of  puberty  who  have  discovered  some  inequahty  in  the  chest  or  promi- 
nence of  the  lower  ribs  perhaps,  but  who  present  no  other  signs  of 
rickets.  In  these  cases  it  seems  reasonable  to  assume  that  a  slight  de- 
gree of  bone  softening  existed  in  childhood  and  passed  away  without 
leaving  any  other  sign  than  the  chest  malformation. 

In  a  typical  rhachitic  chest  the  clavicles  are  shorter  and  more  curved 
than  they  naturally  should  be.  The  chest  is  narrow  and  prominent  in 
front ;  it  shows  the  effect  of  lateral  compression,  and  the  sternum  pro- 
jects so  prominently  that  the  name  of  pigeon  breast,  or  pectus  carina- 
tum,  is  commonly  given  to  it.  The  weakest  part  of  the  chest  cavity  is 
at  the  junction  of  the  ribs  and  cartilages,  and  it  is  here  that  the  chief 
yielding  takes  place  and  the  ribs  allow  themselves  to  be  pressed  in  lat- 
erally, while  the  sternum  is  pushed  forward.  Again,  one  side  may 
yield  more  than  the  other  and  a  prominence  of  the  front  part  of  the 
ribs  on  one  side  of  the  sternum  may  be  the  only  deformity.  A  trans- 
verse depression  in  the  chest  known  as  Harrison's  sulcus  also  occurs 
in  the  typical  cases.  It  is  most  evident  just  below  the  nipples.  The 
prominence  of  the  abdomen,  which  is  almost  universal  in  well-marked 
rickets,  adds  to  the  deformity  of  the  chest  by  the  elevation  of  the  lower 
ribs,  on  account  of  the  underlying  distention.  When  the  abdominal 
distention  disappears,  this  fiaring  of  the  lower  part  of  the  ribs  is  some- 
times left  behind. 

A  very  common  deformity  of  the  spinal  column  due  to  rickets  is  a 
backward  bowlike  curve  (involving  the  dorsal  and  lumbar  regions).  It 
is  a  uniform  flexion  of  the  whole  column  and  is  most  prominent  at  the 
junction  of  the  dorsal  and  lumbar  regions.  This  attitude  seems  the 
result  of  a  long-continued  sedentary  position,  with  a  weakness  and  ten- 
derness of  the  muscles,  which  fail  to  hold  the  spine  in  the  erect  posi- 
tion. Rhachitic  children,  as  a  rule,  learn  to  walk  late,  and  this  peculiar 
flexion  seems  a  persistence  and  exaggeration  of  the  position  which  the 
spine  naturally  assumes  in  young  babies,  who  are  propped  up  in  the 
sitting  position.  The  curve  of  the  spine  is  usually  rounded  rather  than 
sharp,  and  the  prominence  is  not  limited  to  one  vertebral  spinous  proc- 
ess, as  is  the  case  in  early  Pott's  disease. 

The  rhachitic  curve  of  the  spine  is,  as  a  rule,  flexible  if  the  child  lies 
upon  its  face  and  is  lifted  by  the  legs.  In  the  acuter  stages  and  after 
marked  bone  changes  have  taken  place  some  stiffness  may  be  seen. 

Scoliosis  is  a  common  deformity  due  to  rickets,  which  has  already 
been  considered. 

Lordosis  is  the  third  of  the  common  spinal  deformities  due  to  rick- 
ets, and  gives  rise  to  a  characteristic  attitude,  the  importance  of  which 
is  much  overlooked. 

The  attitude  of  a  child  affected  with  well-marked  rickets  is  charac- 
teristic.    It  exists  in  most  marked  cases  of  knock-knee  and  bow-legs 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS. 


277 


and  sometimes  in  a  less  degree  with  milder  grades  of  the  affection. 
The  child  stands  with  the  legs  apart,  the  thighs  flexed  and  the  knees 
bent,  the  back  is  arched,  and  the  shoulders  are  thrown  back.  The  cause 
of  this  attitude  has  never  been  quite  clearly  established.  It  is  un- 
doubtedly in  a  measure  the  persistence  of  the  infantile  attitude,  the 
position  which  children  assume  who  are  just  learning  to  walk.  Another 
factor  is  the  protuberant  abdomen,  the  weight  of  which  the  child  seems 
to  counterbalance  by  leaning  backward. 

Deformity  of  the  pelvis  is  induced  by  rickets,  because  the  body 
weight  is  borne  by  a  bony  arch  which  has  lost  part  of  its  supporting 


Fig.  224.— Deformity  of  Spine  in  Rickets. 


power  and  bends  under  weight.  These  pelvic  deformities  have  only  a 
significance  in  regard  to  obstetric  surgery ;  they  occasion  no  trouble  or 
noticeable  deformity  in  themselves,  but  in  females,  when  pregnancy 
comes  on,  their  existence  is  a  matter  of  the  gravest  importance.  The 
subject  is  treated  in  books  upon  obstetrics. 

Except  in  very  severe  cases,  the  ami  bones  are  not  seriously  curved. 
The  curvatures  follow  no  especial  rule,  but  generally  they  are  an  exag- 
geration of  the  normal  curves  of  the  bones.  The  curvature  of  the  arm 
bones  may  be  due  to  creeping  or  to  lifting  the  child  continually  by 
taking  hold  of  the  forearm  in  one  place,  but  often  apparently  is  the 
result  of  muscular  action. 

Coxa  vara  may  exist  in  the  hips.  The  condition  will  be  described 
in  chapter  X. 


2  78 


ORTHOPEDIC  SURGERY. 


The  rhachitic  deformities  of  the  legs  are  of  such  importance  that 
they  will  be  considered  under  the  separate  headings  of  knock-knee  and 
bow-legs. 

Flat-foot  vs,  ■&.  \Q.xy  QQ\v,vc\o\\  accompaniment  ■  of  rickets.  The  affec- 
tion is  considered  under  flat-foot. 

In  general,  the  skeleton  is  not  only  deformed  but  stunted,  and  per- 
sons who  have  rickets  severely  in  childhood  do  not  reach  average  size 


€  % 


Pig.  225.— Attitude  of  Severe  Rickets, 
Showing  Lordosis  and  Rotation  of 
Pelvis. 


Fig.  226. — Extreme  Deformitv  from  Rickets. 


in  adult  life,  as  a  rule.  The  osseous  deformities,  in  most  cases,  persist 
to  a  certain  extent  through  life.  Notably  is  this  true  of  the  shape  of 
the  skull  and  the  chest. 

Important  symptoms  relate  to  the  eruption  of  the  teeth ;  not  only 
are  they  late  and  irregular,  but  they  are  imperfect  generally,  and  unable 
to  resist  decay.  On  the  average  the  first  tooth  appears  about  the  ninth 
month,  and  not  only  is  the  interval  between  the  teeth  longer,  but  the 
order  of  appearance  is  often  abnormal. 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS.  2/g 

Diagnosis. — The  diagnosis  in  fully  developed  rickets  is  simple;  but 
when  the  affection  is  beginning,  its  recognition  may  be  attended  with 
difficulty. 

In  beginning  rickets  certain  symptoms  are  suggestive;  these  are 
restlessness  and  sweating  at  night,  and  especially  universal  tenderness 
when  acute  articular  rheumatism  is  not  manifestly  present.  In  well- 
marked  cases  the  diagnostic  points  are  the  epiphyseal  enlargement  of 
the  ends  of  the  long  bones,  especially  the  wrists  and  the  sternal  ends 
of  the  ribs;  the  prow-shaped  head ;  the  deep,  small  chest;  and  the  big 
belly.  Delayed  dentition  and  an  anterior  fontanel  open  long  beyond 
the  proper  time  are  equally  characteristic.  If  the  disease  has  advanced 
still  further,  one  often  finds  curvature  of  the  bones  of  the  legs  and 
arms. 

Delay  in  learning  to  walk  should  also  excite  suspicion  of  the  pres- 
ence of  rickets. 

Differential  Diagnosis. — From  Pott's  disease  rhachitic  spinal  curves 
are  sometimes  not  easily  distinguished.  Young  children  a  few  months 
old  are  not  infrequently  brought  for  examination  on  account  of  a  prom- 
inence in  the  back  and  a  great  deal  of  crying  in  being  lifted  or  handled. 
At  the  junction  of  the  lumbar  and  dorsal  regions  a  prominence  may  be 
present,  involving  several  vertebrae,  which  may  or  may  not  be  obliter- 
ated when  the  child  lies  on  its  face  and  is  lifted  by  its  feet  from  the 
table.  Sometimes  the  constitutional  evidences  of  rickets  are  so  marked 
that  the  diagnosis  is  clear ;  Pott's  disease,  when  it  occurs  in  young  chil- 
dren, begins  often  in  this  location  and  in  this  way.  The  writers  have 
seen  cases  in  which  doubtful  kyphoses  of  the  same  characteristics  have 
been  kept  under  observation  and  treatment,  and  one  case  has  proved  to 
■be  rhachitic,  while  another  developed  into  clearly  marked  Pott's  disease. 
Rhachitic  kyphosis  is  more  common  than  Pott's  disease  in  children  un- 
der eighteen  months,  and,  although  the  presence  of  rickets  does  not 
rigidly  exclude  the  possibility  of  Pott's  disease,  yet  when  the  general 
signs  of  rickets  are  present,  it  is  safe  to  assum.e  that  in  most  cases  the 
kyphosis  will  disappear  under  treatment.  In  doubtful  cases  time  alone 
will  clear  up  the  question. 

Prognosis. — When  the  disease  is  left  to  itself  it  generally  runs  its 
course,  and  after  a  decided  degree  of  bony  deformity  has  occurred  the 
process  of  bone  softening  is  spontaneously  arrested,  and  the  bones 
harden  in  their  deformed  condition. 

Spontaneous  arrest  of  the  disease  may  take  place  at  any  stage  with- 
out treatment,  but,  as  a  rule,  in  severe  cases  not  before  a  serious  degree 
of  bony  deformity  has  been  produced.  When  the  disease  is  treated 
efficiently,  the  prognosis  as  to  life  is  always  favorable,  unless  some  seri- 
ous complication  is  present,  and  the  disease  is,  as  a  rule,  easily  amenable 
to  treatment. 


2  8o  ORTHOPEDIC  SURGERY. 

The  k3'phosis  above  alluded  to  disappears  or  diminishes  with  the 
growth  of  the  child.  Lateral  curves,  however,  are  more  permanent. 
As  a  rule  the  bony  deformities,  such  as  epiphyseal  enlargement,  dimin- 
ish with  growth,  but  remain  through  life  to  a  certain  degree. 

Treatment — The  treatment  of  rickets  consists,  first,  in  the  proper 
feeding  of  the  child.  For  what  this  food  should  be  the  reader  is  re- 
ferred to  works  on  the  diseases  of  children.  In  addition  to  this  diet,  it 
is  desirable  to  give  to  rhachitic  children  of  over  six  months  meat  juice 
or  raw  beef  in  small  quantities  and  orange  or  lemon  juice.  Drug  treat- 
ment is  manifestly  secondary  in  importance  to  careful  regulation  of  the 
diet  and  hygiene.  A  remedy  much  advocated  in  the  treatment  of  rick- 
ets is  phosphorus.  It  is  given  in  doses  of  j-i-Q  to  y4-^  of  a  grain  three 
times  a  day.  It  may  be  given  in  the  form  of  the  officinal  phosphorated 
oil  mixed  with  olive  or  almond  oil.  The  writers  have  seen  but  little 
benefit  from  its  use,  and  believe  that  simple  tonics  accomplish  as  much 
as  any  drug.  The  syrup  of  the  iodide  of  iron  seems  a  useful  prepara- 
tion.    Cod-liver  oil  is  of  use. 

Hygiene  ajid  Gefieral  Surroiindmgs. — Rhachitic  children  should  be 
bathed  daily,  preferably  in  salted  water,  and  rubbed  vigorously.  Warm 
woollen  clothing  should  be  worn  and  they  should  go  out  daily.  Espe- 
cial care  should  be  taken  to  keep  them  in  sunny,  well-ventilated  rooms ; 
their  meals  should  be  regular,  and  they  should  be  obliged  to  eat  slowly. 
The  bowels  should  be  watched  and  kept  regular,  and  every  care  should 
be  paid  to  keeping  the  child's  general  condition  as  good  as  possible  in 
every  way.  The  seashore  hospitals,  now  established  in  Italy,  France, 
Germany,  and  America,  provide,  with  proper  nursing,  air,  and  food,  the 
best  prophylactic  against  rickets. 

The  discussion  of  the  operative  and  mechanical  treatment  of  rickets 
will  be  taken  up  under  the  head  of  knock-knee  and  bow-legs. 

OSTEOMALACIA. 

Osteomalacia  is  a  process  somewhat  similar  to  rickets  in  causing 
softening  of  the  bones.  Although  the  pathological  processes  in  the 
two  diseases  are  distinct,  there  is  a  question  whether  the  two  diseases 
are  not  more  closely  allied  than  has  been  supposed.' 

In  osteomalacia  there  is  absorption  of  the  lime  salts,  beginning  in 
the  marrow  of  the  bone  and  affecting  first  the  spongiosa.  The  medulla 
becomxcs  hypersemic  and  there  is  an  increase  of  lymphoid  and  fatty  ele- 
ments. The  medullary  cavity  extends  at  the  expense  of  the  cortical 
part,  and  the  resistance  of  the  bone  is  so  impaired  that  it  bends  or 
breaks.  The  periosteum  is  likely  to  be  thickened  and  vascular.  There 
is  some  tendency  to  new  bone  formation,  especially  at  the  site  of  fract- 

'  Joachimsthal:  Handb.  der  orth.  Chir..  1904.  i..  p.  77.— Kassowitz :  Wiener 
med.  Woch.,  1901,  38. — Morpurgo  :  Cent.  f.  allg.  Path.,xii..  1902. 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS. 


281 


ures.  The  disease  is  most  prevalent  among  the  lower  classes,  and  it 
affects  certain  localities  more  than  others.  Females  are  attacked  more 
often  than  males. 

The  disease  may  be  divided  roughly  into  the  puerperal  and  the  non- 
puerperal form. 

The  former  occurs  during  pregnancy  and  attacks  the  pelvis  most 
often,  extending  perhaps  to  the  spine  and  other  parts  later.  The  out- 
look for  recovery  is  more  favorable  in  this  form. 

The  non-puerperal  form  may  attack  children  or  adults  of  any  age.. 


Fig.  227. — Case  of  Osteomalacia  in  a  Girl  of 
Fifteen  Years.  Showing  deformities  of 
legs  and  arms.     (C.  F.  Painter.) 


Fig. 


—Skeleton  in  Osteomalacia. 
(Warren  Museum.) 


Its  etiology  is  unknown,  and  it  begins  most  often  in  the  lower  ex- 
tremities or  in  the  skull.  The  progress  is  slow  and  the  outlook  un- 
favorable. 

The  symptoms  consist  of  dull  pain  and  perhaps  tenderness  in  the 
affected  parts,  hyperaesthesia  of  the  skin,  and  discomfort  in  walking  or 
sitting.  This  is  followed  or  accompanied  by  yielding  of  the  bones  and 
fractures,  complete  or  incomplete. 

Osteomalacia    iti   children   is    seen    at    times,   and    its    relation   to 


22,2 


ORTHOPEDIC  SURGERY. 


rickets  is  obscure.'     Both  conditions  may  evidently  exist  in  the  same 
patient." 

The  treatment  of  the  disease  must  be  directed  to  the  rehef  of  the 
symptoms  and  must  be  conducted  on  general  principles. 

CHONDRODYSTROPHIA   FCETALIS. 

Chondodystrophia  foetalis  (achondroplasia — foetal  rickets). 

Although  this  condition  is  described  frequently  under  the  name  of 
foetal  rickets,  it  is  essentially  a  different  pathological  process.'  Clini- 
cally the  children  at  birth  seem  to  pre- 
sent the  signs  of  a  severe  grade  of  rickets 
which  has  run  its  course.  The  head  is 
large  and  the  bridge  of  the  nose  depressed. 
There  is  beading  of  the  ribs  and  perhaps 
flattening  of  the  sides  of  the  chest.  The 
long  bones  of  the  extremities  are  short- 
ened and  perhaps  bowed  and  enlarged 
near  the  joints. 

The  essential  pathological  process  is, 
however,  a  disturbance  of  the  normal 
process  of  ossification  of  the  primary 
cartilage.  The  cartilage  atrophies  and 
the  process  of  ossification  takes  place  ab- 
normally early.  The  affection  apparently 
begins  between  the  third  and  sixth  months 
of  intrauterine  life  and  has  almost  ceased 
at  birth.  It  does  not  involve  bones  which 
exist  only  in  cartilage  until  a  late  period 
of  intrauterine  life,  and  this  accounts  for 
its  distribution.  The  medullary  canal  of 
the  long  bones  is  diminished  in  size  and 
there  is  a  periosteal  overgrowth  at  the 
epiphyses  simulating  the  real  enlarge- 
ment occurring  in  rickets. 

In  true  chondodystrophia  the  bones 
will  remain  distorted,  the  joints  will  prob- 
ably be  limited  in  their  range  of  motion, 
and  the  general  growth  of  the  body  retarded.  The  milder  cases  may 
reach  adult  life. 

'  Roos  :  "  Schwere  Knochen-Erkrank.  im  Kindesalter — Osteomalacie  ?  Rachi- 
tis ?"     Zeitsch.  f.  klin.  Med.,  Iv.,  1903. 

-Recklinghausen:  Wien.  med.  Woch.,  1S98. — Joachimsthal :  Handb.  f.  orth 
Chir.,  1904,  i. ,  p.  79. 

"J.  L.  Morse:  Arch,  of  Pediatrics,  August,  1902  (with  bibliography). 


Fig.  229.- 

talis, 


-Chondrodystrophia    Foe- 

"  Conarenital  Rickets." 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS.  283 

The  treatment  can  only  be  palliative,  and  must  consist  of  manipu- 
lation and  massage  of  the  restricted  joints  and  the  prevention  of  bow- 
ing of  the  spine  when  it  is  threatened  by  the  use  of  a  brace  or  by  rest 
in  the  recumbent  position. 

Congenital  rickets  is  a  name  that  may  be  applied  to  cases  in  which 
ordinary  rickets  obviously  exists  at  birth,  but  not  to  those  cases  in  which 
it  has  reached  the  severe  grade  just  described. 

KNOCK-KNEE   AND    BOW-LEGS. 

The  surgical  interest  in  rickets  is  centered  on  the  bony  deformities 
which  result  from  the  disease  and  persist  after  the  morbid  process  has 
ceased  its  activity. 

The  curves  of  the  bone  are  various,  but  those  which  are  chiefly  in- 
teresting to  the  orthopedic  surgeon  are  those  of  the  lower  extremity, 
knock-knee  and  bow-legs. 

KNOCK-KNEE. 

Knock-knee,  ox  genu  valgum,  is  the  name  applied  to  an  internal  an- 
gular prominence  of  the  knee,  in  which  the  bones  of  the  \^g  form  an 
abnormal  lateral  angle  with  the  bones  of  the  thigh,  and  this  angle 
opens  outward. 

This  condition  is  also  known  in  English  as  in-knee ;  in  Latin  as  genu 
introrsum ;  in  German  as  Knickbein,  X-bein,  Backerbein,  Ziegenbein, 
Kniebohrer,  Knieng,  and  Schemmelbein ;  in  French  as  genou  cagneux, 
genou  en  dedans ;  and  in  Italian  as  ginocchio  torto  all'  indentro. 

Occurrence  and  Etiology. — The  deformity  is  one  of  common  occur- 
rence, but  not  so  common  as  bow-legs.  In  12,694  cases  of  orthopedic 
affections  treated  at  the  Children's  Hospital,  Boston,  there  were  1,807 
cases  of  bow-legs  and  753  cases  of  knock-knee.  Both  deformities  affect 
boys  more  often  than  girls. 

Knock-knee  is  a  deformity  which  appears  for  the  most  part  shortly 
after  the  children  learn  to  walk ;  it  appears  also  between  the  ages  of 
twelve  and  eighteen.     Exceptional  cases  occur  at  any  age. 

Knock-knee  occurring  in  the  first  period  named  is  almost  always 
associated  with  general  rickets,  and  is  sometimes  called  crcnu  valnivi 
rhachiticum,  to  distinguish  it  from  the  form  occurring  at  puberty,  which 
is  spoken  of  ?l'&  genu  valgum  staticuni  or  adolescentiuni.  Many  efforts 
have  been  made  to  identify  this  later  form  also  with  rickets,  to  consider 
it  a  local  rhachitic  process,  a  form  of  "latent  rickets."  The  form  of 
knock-knee  occurring  in  adolescence  especially  affects  persons  whose 
occupation  compels  them  to  be  most  of  the  time  in  a  standing  position, 
and,  as  a  rule,  tht>se  affected  are  individuals  of  feeble  physique. 

Other  cases  of  knock-knee  are  produced  as  a  late  result  of  muscu- 


2  84 


ORTHOPEDIC  SURGERY. 


lar  paralysis.     Fractures  about  the  joint  and  destructive  ostitis  of  the 
knee  are  also  causes  of  knock-knee  in  their  late  history. 

Mechanical  Production  of  Knock-knee. — While  the  chief  cause  of  the 
deformity  seems  to  be  a  static  one,  due  to  the  superimposed  body 
weight,  pressure  from  faulty  position  and  abnormal  strain,  as  has  been 
shown  by  Dane,  may  be  a  factor  in  the  production  of  bony  curves. 
Other  causes  are  to  be  found  in  peculiar  gait,  distributing  the  weight 
and  strain  in  an  unusual  manner. 

The  normally  formed  human  being  in  the  upright  position  stands 
with  a  certain  amount  of  knock-knee.  The  femurs  form  an  angle  of 
15°  with  each  other  and  sometimes  more,  and,  as  a  result  of  this  oblique 
direction,  the  inner  condyle  of  the  femur  must 
be  longer  than  the  outer.  When  a  normally 
formed  person  stands  erect  with  the  heels  to- 
gether, if  a  plumb  line  be  dropped  from  the  head 
of  the  femur  it  will  be  seen  to  fall  outside  of  the 
centre  of  the  knee-joint ;  and  this  will  happen  to 
a  greater  extent  in  the  female  than  in  the  male. 

It  is  therefore  evident  that  the  external  con- 
dyle of  the  femur  and  the  corresponding  facet  of 
the  tibia  transmit  more  body  weight  than  do  the 
corresponding  internal  articular  surfaces,  because 
the  centre  of  gravity  lies  outside  of  the  centre 
of  the  joint. 

To  maintain  an  erect  position  with  the  feet 
together  requires  muscular  action.  If  the  stand- 
ing position  is  to  be  maintained  for  a  long 
time,  or  for  a  short  time  in  the  case  of  children  or  feebly  developed 
adults,  the  instinctive  disposition  is  to  substitute  ligamentous  for  mus- 
cular support.  This  can  be  accomplished  by  keeping  the  knee  extended 
and  separating  and  everting  the  feet.  It  is  the  attitude  assumed  by 
children  learning  to  walk  and  by  tired  adults.  This  attitude  is  often 
spoken  of  as  "the  attitude  of  rest." 

From  this  position  more  weight  than  before  is  transmitted  through 
the  external  condyle  and  less  through  the  internal  one.  If  angular 
deformity  takes  place  finally,  all  the  weight  is  transmitted  through  the 
external  condyle. 

Two  results  may  follow  from  this :  stretching  of  the  internal  lateral 
ligament  and  atrophy  of  the  external  condyle. 

The  stretching  of  ligaments  when  subject  to  undue  tension  is  too 
familiar  a  pathological  process  to  require  comment.  The  atrophy  and 
retarded  growth  of  bone,  and  especially  rhachitic  bone  which  is  sub- 
jected to  pressure  and  strain,  are  well  known.' 

'  Lane  :  Guy's  Hosp.  Rep.,  vol.  xxviii. 


Fig.  230  — Axis  of  a  nor- 
mal leg,  and  of  one 
Affected  with  Knock- 
knee. 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS.  285 

Flat-foot  ordinarily  coexists.  Sometimes  it  must  stand  in  a  causa- 
tive relation  to  knock-knee ;  sometimes  it  is  more  the  result  than  the 
cause,  but  commonly  they  are  both  the  results  of  the  same  faulty  atti- 
tude, assumed  as  a  result  of  muscular  fatigue  and  weakness.  Flat-foot 
is  more  easily  produced  than  knock-knee,  and  is  more  common. 

It  is  proper  to  recognize  the  class  of  cases  when  the  femur  is  appar- 


FiG.  231.— Slig-ht  Knock-knee. 


Fig.  232.— Moderate  Knock-knee. 


ently  normal,  but  the  articulating  surfaces  on  the  head  of  the  tibia  are 
oblique. 

In  still  a  third  class  of  cases  the  deformity  is  due  not  so  much  to 
primary  joint  obliquity  as  to  a  bend  in  the  diaphysis  of  the  femur  or  the 
tibia  just  above  or  just  below  the  joint.' 

There  are,  then,  three  bony  deformities  likely  to  be  found  in  cases 
of  knock-knee,  viz.: 

'  Arch.  f.  klin.  Chir.,  1S79,  xxiii. 


286 


ORTHOPEDIC  SURGERY. 


(a)  Difference  in  the  size  of  the  condyles  of  the  femur. 
{b)  Inequality  in  the  articular  facets  of  the  tibia. 
{c)  Bending  of  the  diaphyses    of   the    bones    above  or  below  the 
joint. 

In  severe  cases  the  tibia  is  found  to  be  rotated  outward. 
The  internal  ligaments  are  hypertrophied,  and  the  muscles  and  ten- 
dons on  the  inner  aspect  of  the  leg  are,  of  course,  stretched.     The  pa- 
tella lies  farther  outside  than  it  should  do.     In  some  it  may  be  seen 

that  the  outward  rotation  of  the 
tibia  is  so  marked  that  a  sort  of 
compensatory  inversion  of  the 
feet  has  been  acquired  almost  to 
the  condition  of  varus  to  aid  in 
keeping  balanced. 


Fig. 


-Severe  Knock-knee  due  to   Rick- 
ets.    Seen  from  behind. 


Fig.  234. — Slig-ht  Knock-knee  Resulting- 
from  Tuberculous  Disease  of  the  Left 
Knee.     Now  cured. 


Symptoms. — Subjective  symptoms  in  knock-knee  are  almost  always 
absent.  Children  and  adults  tire  more  easily  than  they  should  when 
they  have  knock-knee,  and  sometimes  pain  and  sensitiveness  are  com- 
plained of  over  the  internal  lateral  ligament  of  the  knee ;  as  a  rule  those 
with  knock-knee  are  clumsy  and  have  a  poor  sense  of  balance.  In 
young  children  with  knock-knee  and  active  rickets  locomotion  is  gen- 
erally difficult,  while  in  adult  cases  there  is  less  difficulty  in  walking, 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS.  287 

even  in  severe  cases,  than  would  be  expected  from  the  degree  of  the 
deformity. 

In  the  standing  position  it  is  noticed  that  the  knees  are  unduly 
prominent  on  the  inside  aspect  of  the  leg,  and  that  the  tibi?e  diverge  sO' 
that  the  feet  are  perhaps  only  a  few  inches  apart,  or,  again,  in  severe 
cases,  a  considerable  distance.  In  cases  in  which  the  angular  deform- 
ity is  very  great,  the  patients  find  the  easiest  position  for  standing  is- 
with  one  knee  behind  the  other,  so  that  in  this  way  the  feet  may  be 
brought  together. 

If  the  child  stands  with  the  feet  together  one  knee  is  generally  a 
little  hyperextended  and  the  other  slightly  flexed,  so  that  they  appar- 
ently come  together. 

The  gait  of  a  patient  with  double  knock-knee  is  distinctive.  The- 
gait  is  a  rolling  one,  consisting  of  a  series  of  slight  lurches,  which  are, 
however,  not  nearly  so  marked  as  in  bow-legs  or  congenital  dislocation 
of  the  hip ;  while  what  is  particularly  noticeable  is  the  outward  throw 
of  the  leg  when  it  is  being  brought  forward. 

The  gait  is,  moreover,  slightly  modified  by  the  fact  that  in  severe 
cases  the  thighs  and  consequently  the  knees  are  slightly  flexed. 
"  Toeing  in  "  is  common,  even  in  the  slighter  grades. 

When  the  deformity  is  unilateral  the  limp  is  less  marked.  Lateral 
curvature  is  sometimes  induced  by  the  unilateral  deformity. 

On  manipulation,  the  knee-joint  is  often  movable  in  a  lateral  plane 
through  an  arc  of  several  degrees.  In  these  cases  the  deformity  is,  of 
course,  increased  when  weight  is  put  upon  the  affected  leg,  so  that  in 
walking  and  standing  it  reaches  its  maximum. 

The  angular  deformity  disappears  when  the  knee  is  flexed  to  a  right 
angle,  except  in  cases  in  which  the  chief  deformity  is  in  the  tibia.  But 
if  the  knee  be  flexed  while  the  hip-joint  is  still  extended,  the  deformity 
does  not  entirely  disappear,  though  it  is  very  much  diminished. 

The  practical  point  is,  that  as  the  deformity  is  most  severe  when 
the  leg  is  in  the  extended  position,  all  mechanical  treatment  applied 
to  the  correction  of  knock-knee  must  be  to  the  fully  extended  leg. 
When  the  leg  is  fully  flexed  the  inequality  in  the  length  of  the  condyles 
is  most  evident,  as  seen  in  outline  from  the  anterior  surface  of  the 
thigh.  This  may  be  registered  by  shaping  a  lead  strip  to  the  lower  sur- 
face of  the  femur  when  the  knee  is  fully  flexed,  and  drawing  an  outline 
on  paper  from  the  lead  strip,  which  should  be  stiff  enough  to  keep  its 
shape. 

Occasionally  one  sees  a  combination  of  knock-knee  and  bow-legs  in 
the  same  subject. 

Loose  Knees. — In  young  children  beginning  to  walk,  who  have 
grown  rapidly  or  who  have  perhaps  the  mildest  degree  of  rickets,  there 
is  often  developed  a  laxity  of  the  knee-joint  which  may  require  treat- 


288  ORTHOPEDIC  SURGERY. 

ment.  On  account  of  the  mechanical  conditions  explained  above  they 
stand  with  the  knees  prominent  inward,  but  the  deformity  disappears 
on  lying  down  and  no  overgrowth  of  the  internal  condyle  is  to  be  found. 
The  knees  can  easily  be  hyperextended  and  are  abnormally  movable 
laterally.  Such  children  are  unsteady  on  their  feet  and  the  apparent 
knock-knee  is  noticed.  The  treatment  consists  of  the  measures  to  be 
described  in  speaking  of  the  mildest  cases  of  knock-knee. 


Fig.  235. — Bow-leg-  of  Right  Leg, 
Knock-knee  and  Flat-foot  on 
Left. 


Fig.  236. — Hyperextended  Position  of 
the  Knees,  Frequently  Seen  in  Con- 
nection with  Knock-knee. 


Measiirevie7it  of  the  Deformity. — The  simplest  and  most  reliable 
method  of  registration  is  to  have  the  patient  sit  upon  a  sheet  of  brown 
paper  with  the  legs  extended  and  the  feet  pointing  upward ;  and  then, 
with  a  pencil  held  perpendicularly  to  the  paper,  to  trace  the  outline  of 
the  legs.  No  other  method  can  give  so  accurate  an  idea  of  the  degree 
and  character  of  the  deformity  present,  or  can  afford  so  delicate  a  means 
of  watching  and  recording  the  progress  of  the  case. 

Diagnosis. — The  diagnostic  points  which  mark  the  affection  known 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS. 


289 


as  knock-knee  are  an  inward  angular  deformity  at  the  knee  which  disap- 
pears on  flexion  of  the  leg'  upon  the  thigh.  There  is  also  in  the  latter 
position  to  be  noted  a  relative  prominence  of  the  internal  condyle  of  the 
femur  in  nearly  all  cases. 

In  children  the  large  proportion  of  all  cases  are  rhachitic  and  static, 
while  in  adults  the  purely  static  cause  must  be  assigned.  It  is  not,  in 
general,  justifiable  to  assume  rickets  as  the  cause  of  knock-knee  in 
cases  in  which  there  are  no  distinctive  signs  of  rickets. 

Paralytic  knock-knee  occurs  only  in  severe  grades  of  paralysis.     Its 
diagnosis    is  evident    from    the 
wasted  and  contracted  condition 
of  the  paralyzed  limb. 

Knock-knee  from  destructive 
disease  of  the  knee-joint  is  a  re- 
sult of  severe  tumor  albus  and 
not  of  the  lighter  grades. 

Traumatic  knock-knee  is  of 
two  kinds:  {a)  Resulting  from 
osteotomy  for  genu  varum  and 
overcorrection  of  the  deformity; 
{y)  resulting  from  fractures  of 
the  condyles  of  the  femur  or  of 
the  articular  facets  of  the  tibia, 
which  are  liable  to  cause  lateral 
malposition  of  the  knee. 

The  ,i'-ray  is  of  use  in  defin- 
ing the  chief  location  of  the  de- 
formity when  necessary. 

Prognosis. — In  severe  cases 
it  is  evident  that  so  much  harm 
has  been  done  already,  and  the 
bones  have  come  into  such  faulty 
apposition,  that  spontaneous  improvement  is  not  to  be  expected.  Chil- 
dren with  a  slight  degree  of  knock-knee  which  is  not  progressive  will 
probably  outgrow  it  without  any  treatment  if  in  vigorous  health.  But 
if  the  deformity  is  moderate  or  severe,  the  chances  are  strong  that 
the  affection  will  remain  stationary  or  more  probably  will  become  worse 
as  time  goes  on,  unless  active  treatment  is  begun. 

Treatment. — The  treatment  of  knock-knee  falls  into  three  divisions: 
I.  Expectant.     II.  Mechanical.     III.  Operative. 

I.  The  expectant  method  of  treatment  relies  upon  nature's  efforts 
to  repair  the  deformity ;  efforts  which  are  aided  on  the  part  of  the  sur- 
geon by  keeping  the  child  off  of  its  feet  to  a  greater  or  less  extent,  and 
by  constitutional  treatment  and  by  massage  and  corrective  manipula- 
^9 


Fig.  237. — Case  of  Knock-knee,  Showing  also 
the  Tracings  of  the  Legs  at  an  Interval  of 
Four  Years  with  no  Treatment. 


290  ORTHOPEDIC  SURGERY. 

tion.  In  mild  cases  there  is  a  tendency  to  outgrow  the  deformity,  but 
this  tendency  is  at  a  great  disadvantage  mechanically,  nor  is  it  a  safe 
proceeding  to  wait  for  this  spontaneous  cure  in  any  marked  case  of 
knock-knee.  The  difficult  question  in  the  whole  matter  is  to  decide 
which  cases  can  be  left  to  themselves — a  question  which  cannot  be  an- 
swered categorically. 

An  argument  for  the  spontaneous  outgrowth  of  knock-knee  is  found 
in  the  rarity  of  adult  cases  which  present  themselves  at  clinics. 

When  the  expectant  method  is  chosen  in  rhachitic  knock-knee,  the 
child  should  at  once  be  put  upon  the  constitutional  treatment  for  rick- 
ets. If  the  knock-knee  is  merely  the  outcome  of  a  feeble  general  con- 
dition, the  patient  should  be  most  carefully  looked  after  in  the  matter 


Fig.  238. — Manipulation  in  the  Treatment  of  Knock-knee. 

of  hygiene,  and  tonic  treatment  and  gymnastics  should  be  given,  the 
aim  of  which  should  be  to  strengthen  the  leg  muscles.  As  much  as 
possible  the  patient  should  be  kept  off  of  the  feet,  and  a  change  to 
country  air  is  capable  of  effecting  great  local  improvement  in  feeble 
children. 

The  legs  should  be  rubbed  and  manipulated  each  night.  The  rub- 
bing should  be  the  same  as  that  described  under  infantile  paralysis,  and 
the  manipulation,  in  cases  of  knock-knee,  should  be  directed  to  the 
gentle  correction  of  the  deformity  by  repeated  mild  manual  pressure. 
With  one  hand  the  manipulator  presses  the  knee  outward,  while  with 
the  other  he  presses  the  lower  part  of  the  tibia  inward.  Even  with  a 
very  slight  degree  of  force  a  certain  yielding  can  be  felt  in  the  direction 
of  improvement,  and  then  the  pressure  should  be  relaxed  and  the  limb 
allowed  to  resume  its  first  position.  This  manipulation  should  be  re- 
peated many  times,  continuing  each  pressure  only  a  few  seconds.  Nor 
should  it  ever  be  done  forcibly  or  long  enough  to  make  the  child  cry. 
This  manipulation  faithfully  carried  out  is  an  important  adjuvant,  not 
only  of  expectant  but  of  mechanical  treatment. 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS. 


291 


In  no  case  should  expectant  treatment  be  considered  when  the 
child  is  not  under  sufficiently  close  observation  to  be  seen  every  few 
weeks,  and  to  have  tracings  taken  to  determine  whether  the  deformity 
is  improving  or  is  stationary. 

It  is  advisable  in  early  knock-knee  to  raise  the  inner  border  of  the 
foot  in  order  to  bring  the  line  of  weight  bearing  at  the  knee  as  far  out- 
side as  possible.  For  this  purpose  felt  pads  shaped  to  support  the  arch 
of  the  foot  are  of  use,  or  the  inner  border  of  the  sole  and  heel  of  the 


Fig.  239. —Knock-knee,  Irons  Applied. 
Front  view. 


Fig.  240. — Knock-knee,  Irons  Applied. 

view. 


Side 


shoes  may  be  made  one-eighth  or  one-fourth  inch  thicker  than  the  outer 
border  in  order  to  accomplish  the  same  object. 

II.  Mechanical  Treatment. — Treatment  by  apparatus  aims  at  the 
gradual  correction  of  the  deformity,  commonly  by  making  counter- 
pressure  against  the  internal  condyle  to  prevent  the  further  giving  way 
of  the  knee  and  to  pull  it  outward  to  a  fixed  point  furnished  by  an  out- 
side upright.     Upon  this  principle  all  modern  apparatus  is  constructed. 

In  children  in  whom  the  change  known  as  eburnation  has  succeeded 
rickets,  the  bones  are  so  hard  and  unyielding  that  it  is  almost  hopeless, 
by  means  of  such  mild  traction  as  can  be  exerted,  to  pull  the  knee  back 
into  place.     In  general  terms,  it  is  not  probable  that  mechanical  treat- 


292 


ORTHOPEDIC  SURGERY 


ment  will  be  of  use  after  the  age  of  four  years  has  been  reached  except 
in  slight  cases ;  nor  is  osteotomy  or  osteoclasis  likely  to  be  considered 
before  that  time.     Under  this  age  in  moderate  degrees  of  deformity  the 


Fig.  241.  Fig.  242. 

Figs.  241  and  242.— Knock-knee.     Mechanical 
treatment  for  one  and  one-half  vears. 


Fig.  243.  Fig.  244. 

Figs.  243  and  244. — Knock-knee  Cured  in 
Three  Years  b}-  the  use  of  Simple  Out- 
side Upright.     A  good  average  result. 


outlook  is  good  with  mechanical  treatment,  and  the  younger  the  patient 

the  better  the  outlook. 

Former  orthopedic  methods  are  exemplified  by  methods  of  recum- 
bency, a  method  which  has  practically  be- 
come obsolete. 

In  the  ambulatory  treatment  of  the 
affection,  a  form  which  has  been  in  use  for 
some  years  at  the  Children's  Hospital 
(Chapter  XXI.,  18)  has  proved  itself  effi- 
cient in  practical  use.  It  is  a  light  steel 
rod  attached  below  to  a  steel  sole  plate 
and  jointed  at  the  ankle.  It  runs  up  the 
outside  of  the  leg  as  far  as  the  trochanter, 
and  then  the  rod  is  bent  backward  and  up- 
ward, to  lie  against  the  upper  part  of  the 
buttock  and  to  serve  as  an  arm  by  which 
the  legs  can  be  everted  if  the  child  toes  in 
in  walking.  The  knee  is  drawn  upon  by 
a  square  leather  pad,  pulling  from  the 
shaft  opposite  the  knee. 
There  is  no  advantage  in  carrying  the  outside  uprights  to  a  rigid 

waist  band,  as  is  done  sometimes.     Braces  are  worn  until  the  line  of 

the  leg  becomes  practically  normal. 

III.  Operative  Treatment. — The    modern    operative    treatment    of 

knock-knee  is  comprised  under  the  simple  operations  of  osteotomy  and 

osteoclasis. 

Osteotomy.— T\\Q.  operation  consists  in  the  division  of  part  of  the 


Fig.  245. — Line  of  Cutting  in  Oste- 
otomy for  Knock-knee.  The  pict- 
ure on  the  left  is  the  ordinary 
Macewen  operation.  The  one  on 
the  right  shows  the  removal  of 
a  wedge  of  bone  required  only 
in  the  severest  cases. 


RICKETS,    KNOCK-KNEE,    AND  BOW- LEGS. 


293 


bone  by  the  chisel,  and  the  completion  of  the  procedure  by  fracture  of 
the  partly  divided  bone. 

The  operation  is  performed  as  follows :  The  patient's  leg  is  rendered 
aseptic;  the  patient  lies  on  his  side  with  the  leg  extended,  the  outer 
side  of  the  knee  resting  on  a  sand-bag.  The  skin  and  underlying  tis- 
sues may  be  divided  with  a  knife  over  the  point  of  division  of  the  bone, 
or,  what  is  more  simple,  the  chisel  is  driven  through  the  sound  skin 
into  the  bone  without  any  incision.     This  diminishes  the  bleeding  and 


Fig.  246. — Proper  Position  for  the  Hand  and  Osteotome  in  Performing  Osteotomy. 


simplifies  the  operation.     The  use  of  an  Esmarch  bandage  is  unneces- 
sary. 

The  point  selected  for  fracture  is  the  point  at  which  the  chisel  is  to 
be  inserted.  This  should  be  as  near  to  the  joint  as  is  practicable  with- 
out injury  to  the  joint.  The  chisel  can  be  inserted  on  the  inner  or  outer 
side  of  the  femur.  There  are  no  especial  advantages  of  either  side  for 
the  point  of  entrance  of  the  chisel,  which  is  determined  by  the  custom 
of  the  surgeon.  The  place  most  commonly  selected  is  that  recom- 
mended by  Macewen,'  on  the  inner  side,  a  short  distance  above  the  tu- 
bercle of  the  adductor  tendon.  The  distance  varies  with  the  size  of  the 
patient.  In  children  it  should  be  but  little  above;  in  older  cases,  where 
the  width  of  the  bone  is  to  be  considered,  a  point  one-half  inch  above 

'Brit.  Med.  Journ.,  June  30th,  1S88,  p.  1377.  —  Lancet,  April  21st,  1SS9. 


294 


ORTHOPEDIC  SURGERY. 


the  tubercle  is  the  point  of  election.  The  osteotome  is  driven  into  the 
bone  with  the  blade  at  right  angles  to  the  long  axis  of  the  femur,  and 
by  successive  blows  with  the  mallet  the  operator  cuts  nearly  through 
the  whole  thickness  of  the  bone.  The  osteotome  is  likely  to  become 
wedged  very  firmly  unless  the  precaution  is  taken  to  move  the  handle 
of  the  chisel  laterally  after  each  blow.  In  this  way  alone  can  one  cut 
from  the  front  to  the  back  of  the  bone,  for  driving  the  chisel  straight 
through  in  one  line  accomplishes  but  little.     When  the  chisel  has  dis- 


FlG.    247. — Moderate     Knock-knee     Before 
Operation. 


Fig.  248. — Same  Case  After  Macewen  Oste- 
otomj-. 


appeared  to  a  depth  indicating  that  three-quarters  of  the  bone  has  been 
divided,  it  should  be  withdrawn  and  an  attempt  made  to  fracture  the 
thigh  by  gentle  bending.  If  this  cannot  be  done,  the  osteotome  should 
cut  further,  for  the  common  mistake  is  a  failure  to  divide  the  anterior 
and  posterior  borders  of  the  femur. 

Some  skill  is  required  in  the  use  of  the  osteotome,  which  is  made  to 
serve  not  only  as  an  instrument  for  dividing  the  bone,  but  as  a  probe 
which  enables  the  surgeon  to  determine  what  portion  of  the  structure 


RICKETS,    KNOCK-KNEE,    AND   BOW- LEGS.  295 

he  is  dividing.  The  bone  being  in  its  different  parts  of  different  hard- 
ness, the  resistance  varies,  and  the  locaUzation  of  the  part  cut  is  not 
difficult.  As  little  injury  as  is  possible  should  be  done  to  the  bone,  and 
little  is  inflicted  if  the  osteotome  divide  the  outer  cortex  for  the  width 
of  an  inch  on  the  side  entered  and  undermine  the  cortex  of  the  re- 
maining side,  cutting  through  the  spongy  portion.  The  insertion  of 
different  sized  osteotomes  is  not  necessary.  The  osteotome  should  be 
held  firmly  and  its  direction  carefully  attended  to  by  the  surgeon. 

When  the  bone  has  broken,  unnecessary  manipulation  should  be 
avoided,  but  the  limb  should  be  put  in  a  corrected  position  after  having 
been  overcorrected,  and,  after  an  aseptic  dressing  has  been  applied,  a 
plaster-of-Paris  bandage  should  be  put  on  to  hold  the  leg  in  a  corrected 
position.  But  little  pain  follows  the  operation.  No  change  of  dressing 
is  needed ;  the  plaster  may  be  removed  in  three  or  four  weeks,  another 
reapplied,  and  in  six  weeks  or  more  the  patient  allowed  to  stand  on  the 
limbs. 

In  correcting  the  deformity  it  is  manifest  that  in  one  place  a  gap  is 
left  to  be  healed  by  blood  clot,  and  in  another  place  the  divided  frag- 
ments will  be  pressed  firmly  together.  As  the  periosteum  is  but  little 
damaged,  firm  union  takes  place,  as  has  been  shown  clinically  in  a 
large  number  of  cases  and  by  pathological  specimens  of  cases  dying  a 
year  or  more  after  the  operation.  The  operation,  when  properly  per- 
formed, is  devoid  of  danger,  and  non-union  need  not  be  anticipated  in 
cases  suitable  for  operation. 

Sometimes,  when  the  deformity  lies  chiefly  in  the  head  of  the  tibia, 
the  operation  of  osteotomy  might  be  performed  there  either  alone  or  in 
connection  with  femoral  osteotomy.  The  removal  of  a  wedge  of  bone  is 
rarely  necessary  from  either  the  femur  or  tibia  in  cases  of  knock-knee. 

Much  care  is  needed  in  the  application  of  the  retaining  plaster 
bandage.  After  the  wound  has  been  properly  protected  by  aseptic 
dressings,  the  limb  should  be  carefully  covered  with  cotton,  not  only  to 
allow  for  shrinking  of  the  tissues,  but  to  prevent  undue  pressure  on  any 
projecting  points. 

If  the  limb  has  been  properly  corrected,  which  is  essential  to  the 
success  of  the  operation,  the  application  of  the  bandage  differs  in  no 
way  from  that  employed  in  the  treatment  of  ordinary  fractures.  The 
danger  of  sloughing  under  the  plaster  is  not  great,  but  if  the  surgeon 
desires  to  examine  the  bone  a  window  can  be  cut  in  the  plaster.  The 
bandage  should  not  be  removed  or  the  corrected  position  interfered 
with  until  union  takes  place. 

Osteoclasis. — The  forcible  fracture  of  bone  by  instrumental  or  man- 
ual means  in  knock-knee  is  decidedly  inferior  to  osteotomy,  inasmuch 
as  it  lacks  the  precision  of  that  method ;  more  splintering  occurs,  and 
rupture  of  the  external  ligaments  and  epiphyseal  separation  are  apt  to 


296 


ORTHOPEDIC  SURGERY. 


occur,  as  in  redressement  force.'  It  is  therefore  better  to  limit  the 
use  of  osteoclasis  to  the  correction  of  bow-legs,  where  the  instrumental 
or  manual  force  can  be  applied  to  the  shaft  of  a  long  bone. 


BOW-LEGS. 


Bow-legs  is  the  name  applied  to  the  opposite  deformity  to  knock- 
knee,  which  is  an  outward  angular  deformity  of  the  knee,  or  a  general 


Fig.  249.— Child  Sitting  Turk  Fashion,  Pro- 
ducing, at  Junction  of  Lower  and  Mid- 
dle Thirds  of  Legs,  Anterior  and  Lateral 
Bowing.     (Children's  Hospital  Report.) 


Fig.  250. — Child  with  Bow-legs  in  Ordinary- 
Sitting  Position,  Showing  Fitting  of  One 
Leg  to  the  Other.  (Children's  Hospital 
Report.) 


outward  bowing  of  the  legs,  so  that  when  the  patient  stands  erect  with 
the  heels  together  the  knees  are  a  greater  or  less  distance  apart. 

The  condition  is  also  known  as  genu  varum,  genu  extrorsum,  out- 
knee,  bowed  legs,  or  bandy  legs.  In  German  one  speaks  of  it  as  Sabel- 
bein,  Sichelbein,  O-bein,  and  in  French  as  Genou  en  dehors. 

It  is  single  or  double,  generally  the  latter,  and  may  exceptionally 
exist  in  one  leg  when  knock-knee  is  present  in  the  other. 
'  Codiilla  :  Zeitsch.  f.  orth.  Chir  ,  Bd.  xi. 


RICKETS,    KNOCK-KNEE,    AND  BOW- LEGS. 


297 


Occurrence. — The  deformity  is  almost  always  the  result  of  an  out- 
ward yielding  of  the  long  bones  of  the  leg,  especially  of  the  tibia.  At 
times,  however,  it  is  clearly  due  to  an  obliquity  at  the  knee-joint,  where 
the  external  condyle  appears  the  larger  of  the  two. 

The  anatomical  changes  found  are  those  of  rickets.  The  bending 
of  the  bones  is  in  most  cases,  like  the  other  deformities  of  rickets,  a 
simple  yielding,  without  fracture  or  destruction  of  bone  tissue. 

Causation. — -Bow-legs  is  essentially  a  rhachitic  deformity  in  chil- 
dren, and  true  bow-legs  can  occur  only  in  a  child  whose  bones  are  soft 
enough  to  bend,  easily.  It  occurs  in  the  first  three  or  four  years  of  life, 
and  ordinarily  in  connection  with  general  rickets ;  sometimes,  however, 
other  rhachitic  manifestations  are  absent ;  but  the  yielding  of  the  bones 
in  a  child  of  this  age  must  of  itself  be  accounted  sufficient  evidence  of 
rickets. 

Bow-legs  of  a  marked  type  are  seen  in  children  who  are  too  young 
ever  to  have  borne  their  weight  upon  their  legs.  To  account  for  this, 
one  must  assume  a  lateral  press- 
ure from  carrying  and  from 
the  sitting  position,  along  with 
the  possibility  of  some  distor- 
tion from  tonic  muscular  pull. 
Early  walking,  so  much  talked 
about  as  a  cause  of  bow-legs, 
is  not  to  be  accounted  a  factor 
of  any  importance  in  their  pro- 
duction unless  rickets  in  some 
degree  is  present. 

Why  the  bones  should  bend 
outward  as  they  do  is  a  question  which  is  by  no  means  settled. 

The  child  with  rickets  stands  with  thighs  flexed  and  the  lumbar 
spine  arched  forward;  once  given  this  condition,  it  is  easy  to  see  how 
bow-legs  arise.  As  the  thighs  flex  the  knees  are  separated  and  the 
femurs  rotate  outward  on  their  own  axes;  as  a  result  of  this  the  line  of 
gravity,  instead  of  falling  outside  of  the  knee-joint,  as  we  have  seen  was 
the  case  in  the  normal  erect  position,  falls  inside  of  it ;  and  any  yielding 
of  the  bones,  of  course,  must  take  place  in  the  outward  direction.  With 
the  yielding  of  the  bones  the  line  of  the  legs  falls  farther  and  farther 
outside  of  the  line  of  gravity,  and  the  body  weight  continually  acquires 
better  leverage  to  bend  the  bones. 

Antnior  ciirvaUire  of  the  thigh  and  the  leg  bones  is  manifestly  the 
result  of  body  weight  coming  upon  a  flexed  limb,  conjoined  perhaps  to 
the  action  of  the  most  powerful  muscles  in  the  body  (the  flexor  muscles 
of  the  thigh)  pulling  in  the  same  direction. 

Symptoms  are  absent,  except,  of  course,  those  of  rickets.     But  the 


Fig.  251.  Fig.  252. 

Fig.    251. — Bow-legs,   Gradual    Curve   Involving" 

the  Whole  Leg. 
Fig.  25-2.— Bow-legs,  Curve  mostly  in  Tibia. 


298 


ORTHOPEDIC  SURGERY. 


deformity  is  plainly  evident,  and  even  in  the  milder  cases  the  gait  is 
modified  in  a  characteristic  way.  The  child  walks  with  a  distinct  wad- 
dle and  generally  with  the  feet  wide  apart  and  a  tendency  to  invert  the 
toes.  The  gait  in  bad  cases  bears  a  resemblance  to  the  waddling  gait 
of  double  congenital  dislocation  of  the  hips.  The  line  of  the  leg  lies  so 
much  outside  of  the  line  of  the  centre  of  gravity  that  in  bearing  weight 


Fig.  253. 


-Standing-  Position  of  Child  with 
Moderate  Bow-Legs. 


Fig.  234. — Curve  Involving  Whole  Leg. 


on  the  left  leg,  for  instance,  the  body  must  be  thrown  decidedly  over  to 
the  left  to  bring  it  over  its  line  of  support ;  it  is  in  a  measure  the  re- 
verse of  the  gait  in  knock-knee.  This  lurching  is  inevitable  with  each 
step,  and,  other  things  being  equal,  is  in  a  degree  proportionate  to  the 
amount  of  curve  present. 

The  deformity  is  almost  always  more  conspicuous  in  the  standing 
position,  both  because  these  children  stand  with  the  legs  so  far  apart 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS,  299 

and  because  the  knee-joints  generally  yield  somewhat  in  a  lateral  direc- 
tion when  the  body  weight  is  superimposed. 

The  curve  is  most  often  a  gradual  and  uniform  bowing  of  the  femur 
and  tibia,  so  that  with  the  feet  together  the  outline  of  the  legs  forms  an 
oval  which  in  severe  cases  approaches  a  circle.  A  second  class  of 
cases  presents  a  bowing  chiefly  in  the  lower  third  of  the  tibia  which  is 
more  angular  in  character,  and  the  femurs  are  practically  normal ;  a 
third  class  presents,  either  alone  or  in  conjunction  with  the  other  de- 
formities, a  bowing  forward  of  the  tibia  and  sometimes  of  the  femur- 
also.     These  are  the  three  common  types  of  the  deformity.     At  times 


Fig.  255. — Severe  Anterior  Bow-leg-,  Seen  from  the  Front  and  Side.     (H.  L.  BurreU.) 

the  deformity  lies  chiefly  in  the  knee-joint  and  the  bones  are  compara- 
tively straight. 

Occasionally  the  condition  of  knock-knee  and  bow-leg  existing  in 
the  same  leg  is  seen. 

An  inward  rotation  of  the  lower  part  of  the  tibia  exists  in  bow-legs 
which  causes  "  toeing  in  "  in  walking.  This  is  apparently  a  part  of  the 
process  of  side  bending,  as  a  three-cornered  weight-bearing  body  like  the 
tibia,  in  bending  to  the  side,  finds  less  resistance  in  bending  and  twist- 
ing than  it  does  in  bending  alone. 

Diagnosis. — The  condition  of  bow-legs  is  evident  on  inspection. 
Macewen's  definition  applied  to  this  deformity  would  be,  that  it  was  a 
condition  in  which  a  line  drawn  from  the  head  of  the  femur  to  the  mid- 
dle of  the  ankle-joint  would  fall  inside  of  the  centre  of  the  knee-joint. 


300 


ORTHOPEDIC  SURGERY. 


It  is  often  difficult  to  determine  how  much  of  the  deformity  lies  in 
the  tibia  and  how  much  in  the  femur.     If  the  legs  are  crossed  until  the 

insides  of  the  knees  are  together  when 
the  child  is  in  a  sitting  position,  it  will 
be  seen  whether  the  femurs  include  an 
oval  space  between  them  or  are  parallel 
to  each  other. 

Prognosis. — The  prognosis  in  out- 
ward bow-legs  is  favorable ;  in  anterior 
bow-legs,  less  favorable  under  expectant 
or  mechanical  treatment.  The  prospect 
of  spontaneous  outgrowth  of  the  de- 
formity is  better  than  in  knock-knee, 
and  in  young  children  rational  mechan- 
ical treatment  offers  almost  sure  relief. 
The  prognosis  of  bow-legs,  when  un- 
treated, will  be  considered  more  in  de- 
tail in  speaking  of  the  treatment  by 
expectancy.  Operative  treatment  can 
ameliorate  almost  any  condition  of  de- 
formity and  often  entirely  rectify  it. 

When  the  deformity  is  extreme  or 
the  bones  are  eburnated,  it  is  not,  of 
course,  likely  that  the  child  will  outgrow 
the  bow-legs. 

Treatment. — The  treatment  of  bow- 
legs, like  that  of  knock-knee,  is  to  be 
considered  under  three  heads:  I.  expec- 
tant, II.  mechanical.  III.  operative. 

I.  The  expectant  tj-eatnicnt  is  suited 
to  a  large  percentage  of  cases  of  the 
deformity,  and  its  range  of  applicability 
is  wider  than  in  knock-  knee.  The  me- 
chanical conditions  are  not  so  much  in  favor  of  the  increase  of  the  de- 
formity as  in  knock-knee,  and  the  tendency  in  slight  cases  is  toward 
rectification  in  the  course  of  growth.  In  general,  when  the  curve  is 
uniform,  involving  femur  and  tibia  alike,  the  chances  are  more  favor- 
able for  spontaneous  cure  than  if  the  deformity  is  localized  in  the  tibia 
and  more  angular. 

During  expectant  treatment  the  general  condition  should  be  most 
carefully  attended  to  and  rickets  treated  from  the  first.  The  child 
should  be  encouraged  to  be  off  of  his  feet  as  much  as  possible,  and  the 
legs  should  be  massaged  and  manipulated  each  night,  being  gently  bent 
toward  a  straight  direction. 


Fig.  256. — Anterior  Bow-legs. 


RICKETS,    KNOCK-KNEE,  AND  BOW-LEGS.  301 


In  all  cases  tracings  should  be  taken  at  least  once  each  month,  to 
determine   if  the  deformity  remains  stationary  or  is    improving,  and 
if  after  two  or  three  months  no  improvement  is  evident,  mechanical 
treatment     should    be 
begun. 

1 1 .  Mcchaji  ical  treat- 
ment is  based  upon  the 
principle  of  drawing  the 
knee  inward  to  a  rod 
which  has  counter- 
points  for  sustaining 
outward  pressure  at  the 
upper  part  of  the  thigh 
and  at  the  ankle.  Here, 
as  in  knock-knee,  trac- 
tion from  a  rigid  rod  is 
more  definite  and  more 
satisfactory  than  from 
an  elastic  one.  The 
form  of  apparatus  used 
is  of  little  consequence 
so  long  as  it  answers 
the  indications  and 
holds  the  knee  extended 
(Chapter  XXI.,  31). 
It  is  no  longer  custom- 
ary to  treat  these  cases 
by  recumbency. 

The  apparatus 
shown  (Chapter  XXI.,  19)  is  the  one  generally  in  use  at  the  Chil- 
dren's Hospital  in  Boston,  and  is  serviceable.  It  consists  of  a  steel 
upright,  which  is  attached  below  to  the  sole  plate  of  the  shoe.  It  runs 
up  nearly  to  the  origin  of  the  adductor  muscles,  but  it  must  fall  a  little 

short  of  them  or  it  will  ex- 
coriate the  skin  in  walking. 
The  upright  is  then  bent  for- 
ward and  upward,  and  curved 
to  fit  into  the  groin  and  come 
up  as  far  as  the  posterior  part 
of  the  dorsum  of  the  ilium. 
In  this  way  a  lever  is  provided 
with  which  to  evert  the  feet 
to  any  extent  by  altering  the 
curve  of  these  arms  and  strap- 


FiG.  257.— Bow-legs  Affecting  Chiefly  Bones  of  Lower  Leg. 


Fig. 


Fig.  259. 


Fig.  260. 


Figs.  258,   259,   and  260. — Case  of   Bow-legs.     Prog- 
ress in  three  years  under  expectant  treatment. 


302 


ORTHOPEDIC  SURGERY. 


ping-  them  together  behind.  Pads  for  the  outside  of  the  legs  are  made 
of  leather  and  buckled  by  two  or  three  straps  to  the  upright,  opposite 
the  greatest  convexity  of  the  curve. 

Anterior  tibial  curves  are  not  susceptible  of  improvement  or  cure 
by  mechanical  treatment  except  in  slight  cases  in  which  the  bones  are 
soft.     In  these  cases  it  is  useful  to  apply  to  the  foot  (Chapter  XXI.,  20) 

a  modification  of  the  brace  de- 
scribed above  (Chapter  XXI.,  19). 
The  mechanical  treatment  of 
bow-legs  should  be  advised  in 
cases  in  which  the  deformity  is 
severe  or  sufficiently  obstinate  to 
make  it  doubtful  whether  spon- 
taneous outgrowth  of  the  deform- 
ity will  occur,  because  braces  do 
no  harm  and  do  not  retard  spon- 
taneous improvement.  After  the 
age  of  three  or  four  it  is  not  gen- 
erally worth  while  to  begin  me- 
chanical treatment. 

In  the  case  of  babies  the  ex- 
pectant plan  of  treatment  is  the 
one  to  be  followed  at  first. 

III.  Operative  Treatment. — Os- 
teoclasis.— In  the  case  of  bones 
still  soft  or  in  very  young  chil- 
dren, if  it  is  desired  to  operate  at 
that  stage,  manual  fracture  has  a 
place  in  the  operative  treatment, 
but  even  then  manual  fracture  presents  no  advantage  over  the  osteo- 
clasts. 

Mechanical  fracture  is  made  feasible  by  the  use  of  osteoclasts,  of 
which  the  one  of  Rizzoli  is  the  simplest.  The  appliance  is  easily  under- 
stood from  the  accompanying  illustration.  The  instrument  is  made  of 
heavy  steel,  and  the  rings  and  the  screw  pad  all  slide  on  the  bar  so  as 
to  be  adjustable  to  any  length  of  leg.  The  parts  of  the  apparatus 
which  come  in  contact  with  the  leg  are  padded  so  that  the  edges  shall 
not  cut.  The  instrument  is  applied  to  the  bared  limb,  the  rings  being 
adjusted  as  far  as  is  possible  from  the  point  at  which  fracture  is  desired. 
In  placing  the  rings  of  the  osteoclast  on  the  limb,  care  should  be  taken 
not  to  put  them  too  near  to  the  joints  of  the  ankle  or  knee,  as  the  epiph- 
yses might  be  separated  by  carelessness.  The  screw  is  to  be  adjust- 
ed so  as  to  press  at  the  point  of  election  for  fracture,  which  is  at  the 
point  of  the  greatest  convexity  of  the  curve.     Pressure  is  increased  until 


Fig.  261.  — Bow-leg.    Brace  Applied. 


RICKETS,    KNOCK-KNEE,    AND  BOW-LEGS. 


303 


fracture  of  the  bones  takes  place.  The  fibula  generally  breaks  first, 
the  tibia  shortly  afterward  on  continuing  the  screw  pressure.  The 
fracture  of  the  bones  is  evidenced  by  a  loud  snap  which  can  be  heard 
anywhere  in  the  room. 

The  bone  will  usually  be  found  to  bend  before  fracture  occurs.  If 
the  instrument  is  well  padded  there  will  be  no  danger  of  injury  of  the 
skin  from  the  temporary  pressure  necessary  for  fracture,  although  the 
amount  of  this  pressure  may  be  very  great.  The  skin  will  become 
blanched  or  congested,  but  after  the  removal  of  the  osteoclast  the  color 
will  be  found  normal,  with  but  slight  evidence  of  pressure.  The  fract-, 
ure  will  be  found  to  have  taken  place  opposite  to  the  screw-pad  plate. 

An  excellent  osteoclast,  devised  by  Dr.  R.  T.  Taylor,  of  Baltimore, 
has  the  advantage  of  working  more  rapidly.  It  is,  however,  somewhat 
more  elaborate  than  the  Rizzoli  and  not  so  easily  carried  about. 

After  the  bone  has  been  broken,  the  osteoclast  should  be  removed, 
the  fragments  placed  with  the  hand  in  the  desired  position,  sheet  wad- 
ding carefully  placed  around  the  leg,  and  the  limb  fixed  in  a  plaster 
bandage  and  held  in  a  carefully  corrected    position.      The    bandage 


Fig.  262. — Rizzoli's  Osteoclast. 


should  reach  from  the  toes  to  the  hip,  and  the  limb  should  be  held  in 
the  corrected  position  until  the  plaster  has  hardened  thoroughly.  When 
there  is  a  rotation  of  the  tibia  as  well  as  a  curvature,  care  should  be 
taken  to  see  that  this  also  is  remedied  and  that  the  limb  is  fixed  in  a 
normal  position. 

Experience  has  shown  that  the  procedure  is  ordinarily  free  from 
risk,  and  in  properly  selected  cases  the  danger  of  non-union  after  fract- 
ure may  be  disregarded.  The  fracture  is  a  transverse  one  and  there 
is  no  danger  of  splintering  the  bone      A  number  of  experiments  upon 


304  ORTHOPEDIC  SURGERY. 

the  cadaver  were  made  by  the  writers  with  reference  to  this  point,  and 
it  was  found  that  although  spHntering  will  take  place  in  dry  bone  if 
subjected  to  fracture  by  an  osteoclast,  yet  bone  undried,  as  found  in 
the  dissecting-room,  will  break  transversely ;  the  fracture  takes  place 
as  a  sharp  linear  fracture  half-way  through  the  bone.  The  part  of  the 
bone  nearest  the  side  of  pressure  breaks  with  an  irregular  line  of 
fracture,  as  if  torn. 

The  amount  of  force  required  for  the  fracture  of  an  adult  bone 
is  very  great,  so  much  so  as  to  make  osteotomy  in  most  instances  a 
preferable  procedure. 

Osteoclasis  near  the  joints  is  difficult,  but  in  the  shaft  of  the  tibia 
the  operation  is  an  excellent  one,  yielding  satisfactory  results  with  but 
little  discomfort  to  the  patient. 

Cases    should  not  be  operated  upon   unless  the  bones  are  fairly 


Fig.  263. —Method  of  Applying  Osteoclast. 

Strong — that  is,  not  if  the  rhachitic  process  has  not  been  well  arrested, 
as  recurrence  of  the  deformity  may  take  place. 

As  a  rule,  the  operation  should  not  be  performed  before  the  age  of 
four. 

The  limb  should  remain  in  a  fixed  bandage  for  four  or  five  wrecks, 
and  no  appliance  is  needed  as  an  after-treatment. 

Osteotomy  should  be  employed  in  place  of  osteoclasis  in  cases  of  bow- 
legs (i)  when  the  curvature  is  so  near  the  joint  that  osteoclasis  is  not 
practicable ;  (2)  when  the  bone  is  so  strong  that  osteoclasis  is  not  feasible ; 
(3)  when  several  curves  exist  in  the  same  leg ;  (4)  when  the  curvature  is 
anterior;  (5)  in  cases  of  bow-leg  in  which  the  distortion  is  largely  m 
the  lower  epiphysis  of  the  femur;  (6)  in  cases  m  which  it  is  desired  to 
locate  the  fracture  very  accurately,  as  in  badly  united  fractures  of  both 
bones  of  the  leg  with  displacement. 


RICKETS,   KNOCK-KNEE,    AND  BOW-LEGS.  305 

Osteotomy  for  bow-legs  is  a  similar  operation  to  that  for  knock- 
knee  ;  the  division  of  bone  is  made  wherever  it  appears  most  necessary, 
and  no  formal  operation  can  be  laid  down.  In  young  children  the 
fibula  need  not  be  cut  with  the  osteotome,  but  can  be  broken  manu- 
ally. 

Anterior  Bow-Legs. — In  the  treatment  of  anterior  bow-legs,  i.e., 
where  the  curve  is  forward  and  not  to  the  side,  the  tibia  may  be  broken 
by  the  osteoclast  applied  in  the  usual  way,  and  after  the  fracture  has 
been  loosened  by  the  hands  the  leg  may  be  set  straight.  Tenotomy  of 
the  tendo  Achillis  aids  this  attempt  and  is  generally  necessary.  Oste- 
otomy, however,  as  a  rule  is  more  satisfactory  in  these  cases.  In  ante- 
riorly curved  bow-leg  in  children,  a  linear  osteotomy  can  be  employed 
dividing  the  posterior  two-thirds  of  the  tibia  and  using  the  anterior  por- 
tion as  a  hinge  with  the  interlacing  broken  fibres  and  uninjured  perios- 
teum to  promote  healing.     The  osteotome  is  inserted  in  the  side  of  the 


Fig.  264.— The  Lever  Osteoclast  of  R.  T.  Taj-lor. 

tibia.  By  this  procedure  the  shortening  caused  by  removing  a  wedge 
is  avoided.  Considerable  manipulation  is  necessary  after  the  osteotomy 
to  free  the  fragments  from  the  shortened  posterior  tissue  which  is  nec- 
essary to  give  a  corrected  position.  The  gap  caused  will,  as  in  the  oper- 
ation for  knock-knee,  heal  by  blood  clot.  In  older  cases  a  wedge- 
shaped  excision  may  be  necessary. 

After  osteotomy  it  is  not  necessary  to  wire  the  fragments  of  bone 
together ;  if  they  are  placed  in  apposition  and  fixed,  union  can  be  ex- 
pected to  take  place. 

Ultimate  Results  of  Osteotomy  mid  Osteoclasis. — J.  E.  Goldthwaite 
traced  out  twenty-eight  cases  of  knock-knee  and  bow-legs  operated  on 
in  the  Children's  Hospital,  not  taking  into  account  any  case  operated 
within  a  year  and  a  half  of  the  beginning  of  his  investigation.  There 
were  eleven  cases  of  Macewen's  osteotomy  for  knock-knee  and  eleven 
of  osteoclasis  for  bow-legs,  while  there  were  five  cases  of  anterior  bow- 
ing of  the  tibia  treated  by  osteotomy.  The  average  length  of  time 
after  the  operation  was  four  years,  and  of  these  cases  only  one  had  re- 
20 


3o6 


ORTHOPEDIC  SURGERY. 


lapsed.  That  was  a  colored  boy,  four  and  one-half  years  old,  who  pre- 
sented a  condition  of  extreme  rickets.  He  had  both  knock-knee  and 
bow-legs,  and  osteoclasis  and  osteotomy  were  done  and  the  knock-knee 
had  recurred  somewhat  since  operation. 

Cases  will  be  met  when  several  curves  are  present,  and  the  judg- 


FlG.  265. — Bow-legs  of  Moderate  Degree 
Before  Operation. 


Fig.  266. — Same  Case  After  Osteo- 
clasis. 


ment  of  the  surgeon  will  be  exercised  in  a  choice  of  what  bone  is  to  be 
attacked  and  if  more  than  one  shall  be  operated  upon  at  one  time. 

In  the  hands  of  a  surgeon  skilled  in  these  operations  and  working 
rapidly,  several  bones  may  be  corrected  at  one  sitting.  The  surgeon's 
purpose  should  be  to  correct  those  deformities  which  most  interfere 
with  normal  gait,  and  leave  others  to  the  correction  of  growth. 

It  may  be  said  that  the  results  in  the  treatment  of  these  deformities 
in  childhood  are  exceedingly  satisfactory  as  a  rule,  the  surgeon  aiding 
nature,  and  nature  completing  the  efforts  of  the  surgeon,  so  that  little 
or  no  trace  of  the  previous  deformity  will  remain  in  after-life.  It  is  not 
advisable  to  operate  in  either  bow-legs  or  knock-knee  before  the  age  of 
four  years. 


RICKETS.    KNOCK-KNEE,    AND  BOW-LEGS.  307 

RHACHITIC   CURVES    IN    THE    UPPER    EXTREMITY. 

These  rarely  present  themselves  for  treatment,  and  but  little  further 
need  be  said  except  that  by  means  of  osteotomy  the  curves  of  the  upper 
extremity  can  be  treated  as  readily  as  those  of  the  lower. 

IMPROPERLY    UNITED    FRACTURES, 

The  same  method  can  be  applied  in  the  correction  of  improperly 
united  fractures  of  the  upper  and  lower  extremities.  In  this  class  of 
affections,  however,  vicious  callus  may  be  present  in  such  a  way  that 
more  than  linear  osteotomy  may  be  needed.  The  principles  of  treat- 
ment for  the  correction  of  these  curves,  in  the  main,  are  those  consid- 
ered in  the  treatment  of  rhachitic  curves. 

In  deformity  following  badly  united  fractures,  however,  the  employ- 
ment of  a  narrow  osteotome  applied  freely  at  such  points  as  may  be 
necessary  to  weaken  the  callus  will  be  found  useful. 


CHAPTER  X. 
COXA  VARA  AND  COXA  VALGA. 

Coxa  vara  and  traumatic  coxa  vara. — Etiology. — Pathology.— Symptoms. — Diag- 
nosis.— Prognosis. — Treatment. — Coxa  valga. 

It  has  been  demonstrated  by  Dwight  that  the  normal  range  of  va- 
riation in  the  angle  between  the  neck  and  the  shaft  of  the  femur  is 
much  greater  than  has  been  ordinarily  supposed.  When  these  varia- 
tions are  slight  no  clinical  symptoms  follow,  but  disturbance  of  the 
function  of  the  hip  is  likely  to  result  when  this  angle  is  diminished  be- 
yond a  certain  point. 

The  name  coxa  vara  is  applied  to  the  condition  in  which  the 
neck  of  the  femur  is  bent  downward  sufficiently  to  give  rise  to  symp- 


FiG.  267.— Specimen  of  Severe  Coxa  Vara.    (Robert  Jones.) 

toms.  This  bending  may  reach  such  an  extent  that  the  neck  forms 
with  the  shaft  a  right  angle  or  less,  instead  of  the  normal  angle  of  120° 
to  140°. 

ETIOLOGY. 

Coxa  vara  may  be  unilateral  or  bilateral,  and  affects  males  more 
often  than  females.  It  is,  in  general,  an  affection  of  growing  bone,  and 
is  seen  most  often  in  adolescents,  and  next  most  frequently  in  children. 


COXA    VARA   AND   COXA    VALGA.  309 

although  adults  are  not  exempt.  The  more  frequent  affection  of  ado- 
lescents is  explained  because  the  disability  is  more  noticed  by  them 
than  by  children,  because  the  strain  coming  upon  the  growing  femur  is 


Fig.  268. — Radiograph  of  Same  Specimen.     (Robert  Jones  ) 

greater  the  larger  the  individual,  and  because  the  neck  of  the  femur  is 
relatively  longer  in  them  than  in  young  children.'  The  affection  may 
be  congenital.'^ 

PATHOLOGY. 

The  shape  of  a  growing  bone  is  in  general  determined  by  the  rela- 
tion between  the  strain  coming  upon  it  and  the  resistance  of  its  struct- 
ure. If  these  relations  are  normal,  the  usual  shape  of  the  bone  will  be 
preserved ;  if  the  resistance  is  diminished  or  the  strain  increased,  mod- 
ifications in  shape  are  likely  to  occur.'  The  causes  of  coxa  vara  are, 
therefore,  to  be  sought  in  increased  strain  or  diminished  resistance  in 
the  neck  of  the  femur. 

Coxa  vara  is  to  be  found  in  connection  with  rickets,  osteomalacia, 
acute  osteomyelitis,  and  ostitis  deformans.  The  changes  resulting 
from  the  destructive  processes  of  arthritis  deformans  and  tuberculosis 

'Whitman:  "Orth.  Surgery,"  2d  edition. 

-  Krebel :  "Coxa  Vara  Congenita."  Cent.  f.  Chir. ,  October  17th,  1S96.  — Joa- 
chimsthal :  Zeit.  f.  orth.  Chir.,  xii  ,  i  and  2,  52. 

■Frieberg  and  Taylor:  "  Wolff's  Law."     Orth.  Trans.,  vol.  xv. 


310 


ORTHOPEDIC  SURGERY. 


of  the  hip  may  cause  a  changed  relation  between  the  head  and  shaft  of 
the  femur,  simulating  coxa  vara. 

Coxa  vara  may  exist  in  cases  presenting  no  clinical  or  pathological 
evidence  of  any  condition  causing  a  softening  of  the  bone.  In  certain 
marked  cases  the  change  in  shape  ma}-  be  clearly  seen  without  other 
evidence  of  disease. 

In  addition  to  the  downward  displacement  of  the  head  and  neck  of 
the  femur,  there  is  generally  also  present  a  yielding  of  the  neck  in  the 
horizontal  plane.  The  most  common  bend  of  the  neck  is  that  with  the 
convexity  forward,  so  that  the  leg  is  rotated  outward  and  the  foot 
everted.  In  other  cases,  less  commonly  seen,  the  neck  is  bent  with  the 
convexity  backward,  and  the  foot  and  leg  are  inverted.  In  still  other 
cases  the  depression  of  the  head  and  neck  in  relation  to  the  shaft  may 
be  directlv  downward  without  forward  or  backward  bendinsr.     In  these 


Fig.  269. — Specimen  of  Coxa  Vara,  no  Clinical  History.    (Warren  Museum.) 


cases  neither  eversion  nor  inversion  will  be  marked.  The  changes  may 
be  most  evident  at  the  end  of  the  neck  of  the  femur  nearest  the  tro- 
chanter or  at  the  end  nearest  the    epiphysis.     In    exceptional  cases 

there  may  be  bending  of  the  upper  part  of  the  shaft  of  the  femur. 


COXA    VARA   AND    COXA    VALGA.  31 1 

Traumatic  Coxa  Vara. 

(Fracture  of  the  neck  of  the  femur,  epiphyseal  disjunction,  infraction 

of  the  neck  of  the  femur,  Schenkelhalsbriiche,  etc.) 

Described  under  these  various  names  is  a  changed  relation  between 
the  head  of  the  femur  and  its  shaft,  which  may  be  classed  with  coxa 


Fig.  270. — Specimen  of  Severe  Double  Coxa  Vara  from  an  Adult  Female  (No.  3821 
in  the  Vienna  Pathological  Anatomical  Museum).   (Albert.  1 

vara  of  non-traumatic  origin.  It  is  clearlv  traumatic  in  origin,  follow- 
ing slight  or  severe  accidents.  It  exists  chiefly  in  children  and  is  often 
overlooked.  The  pathological  change  consists  most  often  of  a  displace- 
ment, partial  or  complete,  of  the  epiph^"sis  downward,  and  a  consequent 
elevation  of  the  trochanter  in  relation  to  the  head  of  the  bone.  At  other 
times  the  injur}-  results  in  a  real  fracture  or  infraction  of  the  neck  of 
the  femur,  the  junction  of  the  epiphysis  and  shaft  apparently  escaping 
injury.'' 

•Hofta:  Zeitsch.  f.  orth.  Chir.,  xi.,  3.  52S    (with  bibliography^ — Whitman: 
Am.  Journ.  Orth.  Surgerj-,  ii.,  i. 


312 


ORTHOPEDIC  SURGERY. 


In  some  instances,  while  no  evidence  of  trauma  is  clear,  enough 
strain  coming  upon  the  epiphysis  to  modify  the  growth  of  the  bone  may 
have  existed  without  giving  rise  to  characteristic  symptoms  of  fracture 


Fig.  271.— Coxa  Vara  and  Bending  Outward  of  the  Upper  Shaft  of  the  Femur.    (Albert.) 

or  epiphyseal  separation.  In  other  cases  a  fracture  of  the  neck  of  the 
femur  in  adolescents  or  children,  sufficiently  severe  to  necessitate 
thorough  treatment  by  the  usual  methods,  may  be  followed  months  after 
by  yielding  of  the  neck  of  the  bone  induced  by  the  softening  of  the 
neck  incident  to  callus  formation. 


COXA    VARA  AND    COXA    VALGA. 


313 


SYMPTOMS. 

The  early  development  of  coxa  vara  is  not  likely  to  be  accompanied 
by  marked  symptoms,  the  earliest  signs  noted  being  generally  referred 
to  the  hip-joint,  which  is  the  seat  of  vague  discomfort  and  slight  irrita- 
bility and  pain,  and  walking  is  avoided.  The  characteristic  symptoms 
when  the  deformity  is  established  are  as  follows: 

Shortening  exists  in  unilateral  cases  and  the  trochanter  is  raised 
above  Nelaton's  line  in  both  unilateral  and  bilateral  cases.     In  children 


Fig.  272.— Sagittal  Section  of  Coxa  Vara,  Showing  Rearrangement  of  Trabeculje  to  Com- 
pensate for  Cross  Strain.      (Abbott.) 

the  shortening  may  be  slight.  The  trochanter  in  marked  cases  is  more 
prominent  than  normal. 

Limitation  of  motion  of  the  hipfoint  is  most  marked  in  the  direction 
of  abduction,  which  is  due  not  only  to  a  shortening  of  the  abductors, 
but  to  the  pressure  of  the  trochanter  against  the  ilium  when  the  leg 
is  abducted.  Joint  irritability  is  generally  present  and  may  be  severe 
enough  to  cause  limitation  of  motion  in  other  directions  than  abduction. 

Lameness  2x\di  pain  m.  the  joint  after  exertion  are  fairly  constant 
symptoms.  If  the  affection  is  unilateral,  a  limp  is  noticeable;  if  bilate- 
ral, a  waddling,  restricted  gait  takes  its  place. 

When  a  backward  twist  of  the  trochanter  exists,  the  foot  will  be 
everted  and  flexion  of  the  thigh  will  be  accompanied  by  ez'ersio7i  and 


3H 


ORTHOPEDIC  SURGERY. 


ubductio7i.  When  a  forward  twist  is  present,  inversion  of  the  foot  is 
found.  In  severe  cases  the  thighs  may  be  crossed  in  front  of  the  body 
in  full  flexion. 

Scoliosis  may  result  in  unilateral  cases.     In  bilateral  cases  the  dis- 
tance between  the  trochanters  will  be  greater  than  normal. 


DIAGNOSIS. 

The  recognition  of  coxa  vara  is  not  difficult.  The  top  of  the  tro- 
chanter is  higher  than  normal,  being  above  the  line  drawn  from  the 
anterior  superior  spine  of  the  ilium  to  the  middle  of  the  tuberosity  of 

the  ischium  (Nekton's  line).  Short- 
ening is  present  if  the  affection  is 
unilateral.  A  femoral  twist  is  recog- 
nized by  determining  on  deep  palpa- 
tion the  direction  of  the  trochanter  rel- 
atively to  the  cross  axis  of  the  pelvis 
when  the  leg  is  straight  and  the  patella 
faces  directly  forward.  The  trochan- 
ter points  forward  or  backward,  accord- 
ing to  the  existing  twist.  In  marked 
cases  limitation  in  abduction  is  present, 
and  in  cases  in  which  the  hip  is  strained 
from  inability  to  bear  the  strain  inci- 
dent to  locomotion,  symptoms  of  joint 
irritation  {i.e.,  pain  and  slight  stiffness 
on  passive  motion)  may  be  present. 
The  diagnosis  can  be  aided  by  a 
skiagram. 

Cases  of  coxa  vara  have  been  re- 
garded as  suffering  from  hip  disease 
and  from  congenital  dislocation  of  the 
hip.  Such  mistakes  can  be  avoided 
by  a  thorough  examination  of  the  case. 
In  cases  of  ]iip  disease  of  long  duration 
the  joint  stiffness  is  greater  than  is 
seen  in  coxa  vara.  The  stiffness  af- 
fects all  motions,  and  not  chiefly  ab- 
duction, and  the  trochanter  is  not  elevated  above  Nelaton's  line,  ex- 
cept after  considerable  bony  destruction,  which  wall  be  accompanied 
by  deep  thickening  about  the  joint  and  by  marked  muscular  spasm. 
In  congenital  dislocation  on  deep  palpation  the  head  will  be  discovered 
■outside  of  the  acetabulum.  On  rotating  the  limb  in  congenital  dis- 
location of  the  hip,  the  excursion  of  the  head  will  be  greater  than  that 


Fig.  273.— Traumatic  Coxa  Vara  of  Right 
Leg,  from  an  Accident  Occurring  when 
Patient  was  Four  Years  Old.    (Hoffa.) 


COXA    VARA   AND   COXA    VALGA. 


315 


of  the  trochanter,  the  reverse  being  true  in  coxa  vara.     In  coxa  vara 
the  distance  between  the  trochanters  is  wider  than  normal,  but  this  is 


Fig.  274. — Outline  of  Depressed   Neck  of  Femur  in  Muller's  Specimen.     Contrasted  with 
normal    (m   dotted  line).     (Whitman.) 

not  the  case  in  congenital  dislocation  of  the  hip.     In  coxa  vara,  if  the 
patient  stands  upon  the  affected  limb  and  raises  the  other  from  the 


Fig.  275.— Cross  Section  of  Pelvis  and  Deformed  Femur.     A  scheme   to  show  the  effect  of 
the  deformity  in  limited  abduction.    Dotted  outline  shows  the  normal  relation.    (Whitman.) 


3i6 


ORTHOPEDIC  SURGERY. 


floor,  the  cross  axis  of  the  pelvis  is  held  firmly  at  a  right  angle  with 
the  line  of  the  leg  and  thigh  or  somewhat  above  it,  while  in  congen- 
ital dislocation  of  the  hip  the  pelvis  drops. 

PROGNOSIS. 

In  connection  with  general  rickets,  when  coxa  vara  exists  with  other 
marked  rhachitic  deformities,  the  prognosis  does  not  differ  from  that  of 
knock-knee  or  bow-legs.  In  other  cases  there  seems  no  reason  to  look 
for  spontaneous  cure.  Remissions  in  the  symptoms  follow  the  rest  ne- 
cessitated by  the  joint  irritability  and  may  be  of  considerable  duration. 

TREATMENT 

in  coxa  vara  is  either  expectant  or  operative. 

Conservative  Treatment. — In  the  stage  in  which  the  bone  may 
be  regarded  as  congested  and  not  sufficiently  strong  to  support  super- 
imposed weight,  crutches  or  an  apparatus  which  will  remove  weight 


Fig.  276. — Double    Coxa  Vara    Showing  Eversion   of  Feet  and  Outward    Rotation  of  Legs. 

(J.  E.  Goldthwaite.) 

from  the  head  and  neck  of  the  femur  can  be  employed.  A  convales- 
cent hip  splint  (Chapter  XXI.,  11)  or  a  Thomas  knee  sphnt  (Chapter 
XXI.,  14)  can  be  used  in  unilateral  cases.     In  bilateral  cases  hip-trac- 


COXA    VARA   AND   COXA    VALGA.  317 

tion  splints  with  an  abducted  position  of  the  limbs  are  indicated  if  the 
symptoms  of  joint  irritation  demand  such  thorough  treatment.  Mas- 
sage is  of  benefit  in  stimulating  the  circulation.     When  the  deformity 


Fig.  277.— Case  of  Double  Coxa  Vara.  This  case  was  reported  by  Dr.  George  H.  Monks 
in  the  Boston  Medical  and  Surgical  Journal,  November  i8,  1886.  The  photograph  here 
shown  is  a  recent  one,  having-  been  taken  for  Dr.  Monks  three  or  four  years  ago. 

is  slight,  such  measures  may  be  relied  upon  not  only  to  check  an  in- 
crease of  the  deformity  and  to  allay  the  condition  of  hip  sensitiveness 
which  may  follow  overstrain,  but  also  to  favor  correction  by  a  more 
normal  growth. 

Operative  Treatment. — If  the  deformity  is  sufficiently  severe  to 
occasion  disability,  operative  measures  are  indicated.  These  may  be 
directed  to  restoring  to  the  patient  free  motion  in  the  direction  of  ab- 
duction or  to  the  correction  of  deformity. 

Forced  abduction  may  suffice  in  young  children  and  can  be  accom- 
plished by  abduction  of  the  limb  under  anaesthesia  with  or  without  fas- 
ciotomy,  and  fixing  of  the  limb  for  a  month  or  more  by  a  plaster  spica 


3i8 


ORTHOPEDIC  SURGERY. 


bandage  in  an  abducted  position.  After  this,  massage  and  stretching 
exercises  should  be  prescribed.  Protected  use  should  then  be  resumed. 
Osteotomy  can  be  either  linear  or  cuneiform.  In  linear  osteotomy 
the  bone  is  divided  by  an  osteotome,  cutting  across  the  femur  below  the 
trochanter  minor,  as  described  in 
hip  disease.  The  limb  is  strongly 
abducted,  the  shaft  being  rotated  in 
or  out  to  correct  the  twist  of  the 


Fig.  278,— Fracture  oE  Hip  Four  Years 
after  the  Accident.  Shows  eversion. 
(Whitman.) 


Fig.  279.— Fracture  of  Hip.  Projec- 
tion and  elevation  of  trochanter. 
(Whitman.) 


neck.  Plaster  fixation  with  the  limb  abducted  should  be  maintained 
for  from  four  to  six  weeks.  In  linear  osteotomy  a  surgeon  familiar 
with  the  procedure  can  divide  the  shaft  as  in  osteotomy  for  knock-knee 
without  a  skin  incision,  using  the  osteotome  to  divide  the  skin.  Linear 
osteotomy  requires  the  exercise  of  some  skill  in  its  performance,  with 
the  expectation  of  an  excellent  result.  After  this,  if  the  limb  is  Drought 
into  the  straight  position,  the  former  depressed  angle  of  the  neck  will 
be  changed  to  a  normal  oblique  inclination.     The  bone  gap  caused  by 


COXA    VARA   AND   COXA    VALGA. 


319 


the  rectification  will,  as  is  observed  in  Macevven's  operation  for  knock- 
knee,  fill  by  healing  by  blood  clot  and  subsequent  ossification. 

The  advantage  claimed  for  cuneiform  osteotomy,  or  the  removal  of 
a  wedge-shaped  fragment  from  the  femur  just  below  the  level  of  the 
lesser  trochanter,  is  the  certainty  of  a  sufficient  gap  of  bone  to  correct 
the  deformity.  The  disadvantage  is  that  the  operation  requires  more 
dissection  and  destruction  of  tissue  and  causes  shortening. 

In  cuneiform  osteotomy  a  three-inch  incision  is  made  on  the  outer 
side  of  the  femur,  from  the  top  of  the  great  trochanter  down.  The  tis- 
sues are  separated,  and  by  means  of  an  osteotome  a  wedge-shaped  sec- 


FiG.  280.— Radiograph  of  a  Severe  Rhachitic  Coxa  Vara  in  a  Patient  Six  Years  Old. 

(Joachimsthal.) 


tion  of  the  femur  is  removed.  The  apex  of  the  section  should  be  at  the 
cortex  of  the  femur  opposite  the  lesser  trochanter,  which  should  not  be 
divided.  The  upper  section  of  the  bone  should  be  at  right  angles  with 
the  axis  of  the  shaft  and  the  lower  section  made  at  an  angle,  the  base 


ORTHOPEDIC  SURGERY. 


of  the  wedge  being  three-quarters  of  an  inch  wide,  the  exact  amount 
varying  with  the  size  of  the  bone.  After  the  section  has  been  made 
and  the  wedge  of  bone  removed,  the  uncut  inner  surface  of  the  femur 
is  broken.  The  splintered  fragment  and  the  periosteum  act  as  a  hinge 
and  no  wire  sutures  are  needed,  the  cut  bone  surfaces  being  placed  in 
apposition,  the  top  of  the  great  trochanter  being  pressed  against  the 
ilium  by  abducting  the  limb.  The  limb  should  be  fixed  in  a  plaster 
spica  bandage,  holding  the  pelvis  and  femur  securely. 

Afti-r-TrcatmcJit. — After  the  removal  of  the  plaster  bandage  the 
motion  of  the  limb  should  be  encouraged  without  weight  bearing  by 
passive  movements,  massage,  and  going  about  on  crutches.  After  this 
it  is  a  matter  of  judgment  in  each  case  w^hether  the  patient  may  be  al- 
lowed unrestricted  activity  or  whether  the  neck  of  the  femur  may  still 

possess  too  little  resistance,  in 
which  case  a  protection  splint 
should  be  worn. 

Traumatic  Coxa  Vara. — In 
cases  seen  long  after  the  accident 
the  treatment  does  not  differ  from 
that  described  for-  ordinary  coxa 
vara.  In  recent  cases,  seen  so 
soon  after  the  accident  that  con- 
solidation has  had  no  time  to 
occur,  the  leg  should  be  abducted 
and  fixed  in  that  position  by  a 
plaster-of -Paris  spica.  Traction 
may  be  required  in  exceptional 
cases.  Unprotected  use  of  such 
a  leg  should  not  be  allowed  for  a 
year  after  the  injury. 

Coxa  Valga. 

Coxa  valga  is  the  name  applied 
to  the  condition  which  is  the  re- 
verse of  coxa  vara.  In  this  the 
angle  between  the  neck  and  shaft 
of  the  femur  is  increased  above 
140°.  In  connection  with  this  deformity  also  twists  of  the  neck  of 
the  femur  may  occur.  It  has  been  recorded  as  occurring  in  connec- 
tion with  infantile  paralysis,  in  connection  with  atrophy  following  old 
ankylosis  of  the  knee-joint,  in  osteomyelitis  of  the  pelvic  bones,  in 
severe  rickets,  and  in  osteomalacia.'     It  has  been  recorded  following 

1  Turner:  Zeitsch.  f.  orth.  Chir.,  xiii..  11.— Albert:  "Coxa  Vara  und  Valga," 
AVien.  1899. 


Pig.  281.— Radiograph  of  a  Sagittal  Sec- 
tion of  a  Specimen  of  Coxa  Valga, 
Amputation  of  the  Thigh  having  been 
Done  in  Childhood.     (Turner.) 


COXA    VARA   AND    COXA    VALGA. 


321 


a  severe  fracture  of  the  lower  end  of  the  femur  and  knee-joint.  A 
congenital  case '  has  been  reported  of  double  coxa  valga  in  which  ap- 
parently neither  rickets  nor  trauma  was  present  as  an  antecedent 
cause.     When  symptoms  have  been  reported  they  consist  of  an  a.b- 


FiG.  282.— Radiograph  of  a  Case  of  Coxa  Valga.    (David.) 

ducted  position  of  the  leg  with  eversion,  and  adduction  and  inward  ro- 
tation are  limited.  The  gait  is  not  unlike  that  in  double  coxa  vara. 
A  satisfactory  treatment  of  the  condition  has  not  been  formulated. 

'  David:  Zeitsch.  f.  orth.  Chir. ,  xiii.,  ii.  and  iii.,  360  (with  literature). 
21 


CHAPTER    XI. 
LATERAL   CURVATURE    OF    THE   SPINE. 

Definition.— Frequency.—  Sex.— Age.  —  Patiiology.— Etiology.— Symptoms.— Di- 
agnosis.—Methods  of  record.— Prognosis.— Preventive  measures. — Treat- 
ment. 

DEFINITION. 

By  this  term  is  understood  a  constant  deviation  of  the  spinal  col- 
umn, or  a  portion  of  it,  to  either  side  of  the  median  line  of  the  body, 
with  a  resulting  distortion  of  the  trunk.  The  affection  has  also  been 
called  scoliosis  and  rotary  lateral  curvature. 

In  French  it  is  known  as  ScoHose,  deviation  laterale  de  la  taillc,  and 
in  German  it  is  called  Seitliche  Riickgratsverkrimwmng,  and  Kyphosco- 
liose. 

Lateral  curvature  is  either  congenital  or  acquired.  The  former  va- 
riety, hovi^ever,  is  rare ;  when  present,  it  is  a  result  of  imperfect  or  de- 
fective development.' 

FREQUENCY. 

The  affection  is  a  common  one,  but  its  prevalence  can  only  be  esti- 
mated, as  statistics  gathered  vary  apparently  according  to  the  standard 
of  the  observer. 

Drachmann  reports  scoliosis  in  lYi  per  cent  of  28,125  school  chil- 
dren in  Norway,  while  in  Switzerland '  24.6  per  cent  among  2,314  school 
children  are  reported  to  have  had  lateral  curvature,  in  Moscow  29  per 
cent  of  scoliotics  among  1,664  children  were  found  by  Hagemann,  and 
in  St.  Petersburg  26  per  cent  among  2,333  by  Kohlbach. 

Berend  reports  900  scoliotic  patients  in  3,000  patients ;  Langgaard 
700  in  1,000  cases;  Schilling,  600  in  1,000  (Schreiber).  Whitman  re- 
ports that  scoliosis  was,  next  to  bow-legs,  the  most  common  deformity 
at  the  out-patient  department  of  the  New  York  Hospital  for  Ruptured 
and  Crippled  Children. 

The  distortion  is  seen  more  frequently  in  girls  than  in  boys,  but 
statistics  as  to  the  comparative  frequency  of  the  deformity  in  females 
as  compared  with  males  vary.  It  is  placed  by  different  observers  at 
from  seven  to  four  females  to  one  male. 

^Vogt:  "  Moderne  Orthopadik,"  p.  75.— Schreiber :  "  Orthopadische  Chi- 
rurgie,"  p.  118. 

-  Annales  Suisse  d'Hygiene  Scolaire,  1901. 

322 


LATERAL   CURVATURE   OF   THE  SPINE. 


323 


//5 


JIO 


m 


i\ 


^1 


19 


n 


It  is  possible  that  if  parents  were  as  solicitous  as  to  slight  variations 
in  the  figures  of  their  boys  as  of  their  girls,  the  statistics  would  show  a 
greater  proportion  among  boys  than  has  been  reported.  In  the  lateral 
curvatures  of  young  children  (under  five),  the  males  are  said  to  equal 
or  to  outnumber  the  females.  When  school  children  are  observed,  the 
proportion  of  males  is  very  much  greater  than  when  the  statistics  are 
taken  from  patients  coming  for  treatment.  Some 
of  the  most  severe  forms  are  to  be  seen  among 
males. 

Age. — Although  it  is  probable  that  the  dis- 
tortion exists  to  a  slight  extent  at  an  earlier  age, 
the  majority  of  cases  brought  to  the  surgeon  for 
treatment  are  from  ten  to  sixteen  years  of  age. 
Whitman  reports  39  per  cent  under  fourteen 
years  of  age,  48  per  cent  between  fourteen  and 
twenty-one;  Eulenberg,  over  50  per  cent  between 
seven  and  ten  years  of  age,  and  10  per  cent  be- 
tween ten  and  fourteen. 

Lateral  curvature,  an  abnormality  in  the 
shape  of  the  trunk  by  which  its  symmetry  is 
lost,  is  characterized  by  a  curve  and  twist  of  the 
spinal  column,  causing  an  undue  prominence  of 
one  side  and  other  irregularities  of  contour. 

The  deformity  is  more   readily  understood  if 
the  pathological  changes  are  examined. 


2J  T~  15^^0?-'/0(/-3]0-35^-30f 


PATHOLOGY. 


Fig.  283. — Diagram  show- 
ing the  Progressive  In- 
crease of  Scoliosis  dur- 
ing School  Life.  The 
lowest  grade  in  school 
is  placed  on  the  left. 
The  lower  figure  shows 
the  number  of  children 
investigated  in  each 
grade  and  the  figure  at 
the  top  the  number  of 
scolioses  found  in  each 
grade.     (Scholder.) 


The  pathological  changes  in  true  lateral  curv- 
ature are  not  those  resulting  from  destructive 
disease  of  the  vertebrae,  but  are  the  alterations  of 
bone  induced  by  abnormal  pressure  and  strain. 

The  spinal  column,  as  a  whole,  is  bent  and 
twisted,  and  the  individual  vertebrae  are  in  places 
altered  in  shape  as  well  as  misplaced  from  their 
normal  relation  to  the  vertical  plane  of  the  trunk. 
The  ribs  and  pelvis  may  be  altered  in  shape.  The  muscles  and  liga- 
ments are  altered  in  their  tonicity  and  length,  and  internal  organs  may 
be  displaced. 

Characteristic  of  the  deformity  is  the  combination  of  a  side  curve  of 
the  spinal  column  with  a  twist,  the  spinous  processes  as  a  rule  pointing 
away  from  and  the  vertebral  bodies  being  turned  toward  the  convexity 
of  the  curve.  This  rotation  is  the  result  of  the  structure  of  the 
spinal  column,  which  cannot  bend  to  the  side  without  twisting. 


324 


OR  THOPEDIC  S  UR  GER  Y. 


The  changes  seen  necessarily  vary  according  to  the  stage  of  the 
affection  and  the  degree  to  which  the  deformity  has  developed. 

In  the  earliest  stage  of  scoliosis  slight  if  any  anatomical  change  will 


Fig.  284. — Longitudinal  Section  of  the  Ver- 
tebral Column  of  a  New-born  Child,  Show- 
ing the  Absence  of  Ph\'siolog'ical  Curves. 
(Schulthess.) 


Fig.  285.— Side  View  of  the  Vertebral 

Column  of  an  Adult  Man.    (Schult- 
hess.) 


be  found  in  the  bones,  ligaments,  or  muscles ;  but  in  the  stage  of  fixed 
curves  and  in  the  latest  phases  of  the  affection,  marked  distortion  of 


LATERAL    CURVATURE   OE   THE  SPINE. 


325 


the  whole  spinal  column,  as  well  as  the   individual  vertebrsc,  is   to  be 
observed. 

Wherever  a  side  curve  with  rotation  of  the  spine  tias  taken  place, 
the  bodies  are  crowded  together  on  the  concave  and  separated  on  the 
convex  side  of  the  curve.  Growing  bone  adapts  itself  to  altered  press- 
ure, and  in  time  the  vertebral  bodies  will  be  found  thicker  on  one  side 

than  the  other,  and  changes  in 
shape  of  the  articulating  and 
transverse  processes  will  also 
take   place.      The   transverse 


Fig.  286. — Torsion  in  Lateral  Curvature, 
bar.) 


(vSchrei- 


FiG.  287.— Distorted  Pelvis  in  Lat- 
eral Curvature. 


processes  are  out  of  the  normal  plane;  the  ribs  follow  the  transverse 
processes,  and  show  a  characteristic  projection  on  one  side  and  flatten- 
ing on  the  other. 

If  the  column  is  curved  laterally  in  two  or  three  directions,  rotation 
necessarily  takes  place  in  different  parts  of  it  in  opposite  directions. 
The  projection  of  the  ribs  is  naturally  more  noticeable  than  the  projec- 
tion of  the  transverse  processes  without  ribs,  so  that  in  the  lumbar 
region  the  rotation  seems  slight  when  compared  with  that  of  the  dor- 
sal region. 

The  intervertebral  cartilages  necessarily  twist  with  the  vertebrae 
and  are  compressed  on  one  side  more  than  on  the  other  in  cases  of 
marked  curves ;  in  severe  cases  they  will  be  found  on  measurement 
thicker  on  the  side  of  convexity  than  of  concavity,  so  that  instead  of 
being  flat  they  are  wedge-shaped  from  side  to  side.  In  some  cases 
the  rotation  is  more  marked  than  the  curve,  the  line  of  the  spines  being 
nearly  straight,  while  the  bodies  are  found  badly  out  of  line,  the  axis 
of  rotation  being  near  the  spines. 

Wolff's  Law. — The  adaptation  of  bone  to  pressure  has  been  formu- 
lated in  what  is  known  as  Wolff's  law,  which  is  as  follows:  "Every 
change  in  the  formation  and  function  of  the  bones,  or  of  their  function 


326 


ORTHOPEDIC  SURGERY. 


alone,  is  followed  by  certain  different  changes  in  their  internal  archi- 
tecture and  equally  definite  secondary  alterations  of  their  external  con- 
formation in  accordance  with  mathematical  laws." 

The  relation  of  bone  structure  to  strain,  however,  was  understood 
and  described  by  Sir  Charles  Bell  in  his 
treatise   on    "Animal    Mechanics,"   and 
was  also  described  by  Jeffries  Wyman,  of 
Cambridge/ 


Fig.  288.— Method  Used  for  Producing  Deformitj-  of 
Head  by  Flat-Head  Indians.  (From  Sketcii  from 
Lewis  and  Clark.) 


Fig.  289. —  The  Flat- 
Head  Indian.  An 
old  man. 


There  is  necessarily  a  torsion  of  the  spinal  column  whenever  it  is 
bent  toward  the  side,  and  when  a  curved  condition  of  the  spine  becomes 
habitual  or  constant  the  changed  pressure  in  the  spinal  column  pro- 
duces in  time  alterations  in  the  shape  of  the  vertebral  bodies  and  in  the 


articulating  surfaces. 


It  has  been  shown  that  not  only  do  the  bodies  of  the  vertebrae  give 
evidence  of  torsion  around  the  axis  of  the  spinal  column,  but  there  is, 
in  advanced  cases,  evidence  of  torsion  of  the  bodies  themselves  in 
oblique  and  spiral  longitudinal  striations  on  the  bodies  in  the  place  of 


Fig.  290. — Transverse  Section  of  a  Scoliotic  Thorax.    (Albert.) 

the  usual  vertical  marking,  and  in  a  twist  of  the  spinous  process  and 
lamina  in  its  relation  to  the  vertebral  body.^     The  bodies  lose  their  nor- 


[902 


^"Animal  Mechanics,"  by  Sir  Charles  Bell  and  Jeffries  Wyman,  Cambridge, 
-  Lorenz  :  "  Scoliosis,"  Wien. 


LATERAL    CURVATURE   OF   THE  SPINE.  327 

mal  symmetrical  shape ;  the  spinal  canal  becomes  irregularly  oval  in 
shape,  and  the  transverse  and  articular  processes  are  altered  according 
to  the  position  of  the  vertebrae;  those  on  the  crowded  side  being 
broader  and  lower  than  on  the  convex  side.  The  changed  vertebrae 
vary  according  to  their  relative  position  in  the  curve  and  to  the  direc- 
tion in  which  they  receive  the  superincumbent  pressure,  those  at  the 
site  of  the  greatest  curve  changing  the  most. 

On  section  the  structure  of  the  bones  will  be  found  normal,  except 
that  abnormalities  in  bone  density  and  in  the  trabeculae  will  be  ob- 
served, and  irregularities  in  shape  and  growth. 

The  ribs  are  not  only  displaced,  but  altered  in  shape.     They  are 


Pig.  291. — Horizontal  Section  of  a  Normal  Dorsal  Vertebra.     (Dolega.) 

also  altered  in  the  line  of  their  obliquity,  being  lowered  on  the  side  of 
the  concavity  of  the  curve. 

The  contour  of  the  thorax  is  changed  from  the  altered  shape  of  the 
ribs ;  the  clavicles  remain,  as  a  rule,  unchanged,  but  the  tip  of  the  ster- 
num may  be  deflected  from  the  median  line.  The  ribs  project  back- 
ward at  the  angle  on  the  side  of  the  convexity  of  the  curve  and  forward 
on  the  side  of  the  concavity. 

A  cross  section  of  the  thorax  shows  an  alteration  of  the  diagonal 
axes  of  the  chest,  and  in  the  ordinary  dorsal  right  convex  curve  the 
diagonal  axis  from  the  left  front  side  to  the  right  back  side  of  the  thorax 
is  longer  than  on  the  other  side.     The  different  halves  of  the  thorax, 


32  8  ORTHOPEDIC  SURGERY. 

on  cross  section,  should  be  symmetrical  normally,  but  in  lateral  cur- 
vature the  portion  on  the  convex  side  is  smaller  than  that  on  the  con- 
cave side,  owing  to  the  flattening  of  the  ribs.  The  vertebral  bodies 
are  also  crowded  into  this  half  of  the  thorax,  so  that  there  is  less  room 


Fig.  292.— Section  of  the  Ninth  Dorsal  Vertebra  in  a  Case  of  Right  Dorsal  Scoliosis.    (Dolega.) 

for  expansion  of  the  lung  on  that  side  than  on  the  other  side.  In  the 
severest  cases  of  distortion,  the  lower  ribs  on  one  side  may  rest  upon 
the  crest  of  the  ilium  or  sink  into  the  pelvic  cavity. 

The  muscles  of  the  spinal  column  in  an  early  case  of  lateral  curva- 
ture are  unaffected,  except  in  cases  of  a  purely  paralytic  nature.  In 
dissections  of  advanced  cases  the  muscles  are  found  to  have  degen- 
erated. The  muscles  in  the  concavity  of  the  curve  are  found  neither 
prominent  nor  rigid.  The  prominence  and  rigidity  of  the  spinal  mus- 
cles in  the  lumbar  region  frequently  seen  on  the  convex  side  of  the  lum- 
bar curve  often  convey  to  the  touch  a  doubtful  sense  of  fluctuation,  and 
have  sometimes  led  to  the  suspicion  of  an  abscess. 

In  advanced  cases  of  lateral  curvature,  the  ligaments  on  the  concave 
side  of  the  spinal  column  are  shortened  and  those  on  the  convex  side 
are  elongated.  This  is  the  result  of  adaptive  shortening,  and  is  not 
found  in  the  early  stages  of  the  affection. 

Distortion  of  the  Pelvis  in  Cases  of  Lateral  Curvature  of  the  Spine. 
— The  pelvis  is  not  necessarily  distorted  in  lateral  curvature  of  the 
spine,  but  the  bones  of  the  pelvis  may,  if  not  sufficiently  un3delding  in 
their  structure,  become  altered  by  abnormal  pressure  or  strain.  The 
pelvis  may  assume  the  appearance  of  obliquity  from  a  prominence  of 
one  hip  due  to  the  uncovering  of  the  crest  of  the  ilium  by  the  over-pro- 


LATERAL    CURVATURE  OF   THE  SPINE. 


329 


jecting  ribs,  but  true  obliquit}'  is  exceptional.  When  there  is  irregu- 
larity in  the  length  of  the  legs,  obliquity  of  the  pelvis  necessarily  exists. 
The  spinal  cord  is  not  affected  by  lateral  curvature.  The  spinal  nerves, 
in  consequence  of  the  large  size  of  the  foramina,  are  not  liable  to  suffer 
compression,  but  symptoms  of  nerve-root  pressure  are  at  times  observed 
in  advanced  cases. 

Influence  of  Lateral  Curvature  in  Causing  Displacement  of  Abdomi- 
nal Viscera. — The  abdominal  viscera  are  less  likely  to  be  displaced, 
even  in  severe  cases,  than  the  thoracic  organs,  though  the  liver  ma}-  be 
out  of  place  and  altered  in  form,  according  to  the  direction  and  extent 
of  the  spinal  distortion.  The  spleen  may  suffer  some  compression, 
and  the  aorta  is  necessarily  displaced.  The  lung  on  the  convexity  of 
the  curve  is  much  more  compressed  and  flattened,  and  the  thoracic 
cavity  on  the  concavity  of  the  curve  is  always  found  to  be  much  larger 


Fig.  293.— Experiment  on  Cadaver  Showing  the  Causation  of  a  Right  Curve  %vith  Rotation 
from  Oblique  Superincumbent  Weight. 


than  would  be  expected.  The  lung  on  the  concavity  of  the  curve  may 
be  altered  in  form,  but  is  not  diminished  in  bulk  as  on  the  side  of  con- 
vexity. The  heart  is  generally  found  displaced  toward  the  concavity  of 
the  curve  in  severe  cases. 


330  ORTHOPEDIC  SURGERY. 

ETIOLOGY. 

When  bone  was  reg^arded  as  a  structure  which  was  unchanged  in 
shape  except  by  accident  or  destructive  disease,  the  phenomena  of  lat- 
eral curvature  were  not  easily  understood.  No  evidence  of  disease  or 
traumatism  is  found,  and,  although  the  bones  are  abnormal  in  shape, 
they  are  not  defective.  It  is  now  known  that  bone,  like  other  portions 
of  the  human  frame,  muscle,  and  skin,  is  a  structure  which  adapts  itself 
to  conditions,  being  changed  in  shape  and  strength  under  pressure  and 
strain.  Bone  can  be  deformed  by  abnormal  pressure  without  injury  to 
the  health,  as  is  shown  by  the  flat-headed  Indians,  whose  skulls  were 
shown  by  Clark  to  have  been  distorted  by  pressure  mechanically  applied 
for  a  long  period  in  infancy.  The  foot  of  a  Chinese  lady  is  another 
illustration.  The  shape  of  the  bone,  as  is  well  known,  alters  in  differ- 
ent occupations.  These  alterations  in  bone,  studied  as  they  have  been 
by  Bell,  Wyman,  and  Wolff,  may  be  regarded  as  the  result  of  altered 
conditions. 

The  phenomena  of  lateral  curvature,  curve  and  rotation,  have  been 
produced  experimentally  on  the  cadaver  of  infants  (Bradford  and  Lov- 
ett,  ist  and  2d  eds..  Chapter  "Lateral  Curvature"),  and  in  animals  by 
Wullstein,^  who  produced  scoliosis  by  securing  for  six  months  the  spine 
of  a  growing  dog  by  a  stiff  bandage  in  a  bent  position.  Growing  chil- 
dren, obliged  to  retain  an  abnormal  position  through  paralysis,  often 
acquire  scoliosis,  and  the  Siamese  twins,  prevented  from  normal  atti- 
tudes, developed  similar  deformities.  It  is  not  necessary  to  seek  for 
remote  causes  in  studying  the  etiology  of  scoliosis. 

To  explain  the  development  of  scoliosis  it  is  only  necessary  to  as- 
sume the  existence  of  a  constantly  applied  force  exerted  upon  the  spinal 
column  in  abnormal  directions.  As  the  resistance  offered  by  the  bone 
differs  in  different  portions  of  the  spine,  a  certain  type  of  deformity 
results  from  abnormally  applied  superimposed  weight,  and,  as  individ- 
uals differ,  similar  conditions  do  not  produce  the  same  deformity  in 
different  individuals.  Whatever  favors  abnormal  distribution  of  the 
superimposed  weight  favors  the  development  of  the  deformity,  as  is  also 
true  of  conditions  which  diminish  the  resistance  of  bone.  Of  the  fac- 
tors favoring  abnormal  distribution  of  superimposed  weight,  the  follow- 
ing may  be  mentioned : 

1.  Faulty  attitudes  in  standing  or  sitting. 

2.  Inequality  of  the  length  of  the  limbs  or  other  causes  tilting  or 
twisting  the  pelvis. 

3.  Occupations  which  produce  faulty  attitudes. 

4.  Paralysis  or  weakness  of  the  muscles  of  the  back. 

5.  Congenital  defects,  absence  or  defects  of  the  ribs  or  vertebrae. 

'  Wullstein  :  "  Die  Skoliose,"  Stuttgart,  1902. 


LATERAL   CURVATURE   OF   THE  SPINE.  331 

6.  Torticollis  or  inequality  of  vision  in  the  eyes. 

7.  Contraction  of  the  chest  following  empyema. 

8.  Sacro-iliac  disease. 

9.  Asymmetry  of  the  pelvis. 

Lateral  curvature  is  also  favored  by  causes  which  will  diminish  the 
resistance  of  bone  to  abnormally  applied  weight.  Apart  from  disease 
of  the  structure  of  bone,  these  are:  (i)  rickets  and  osteomalacia;  (2) 
abnormal  lack  of  bone  resistance  of  the  spinal  column,  from  rapid,  ex- 
cessive, or  ill-nurtured  growth. 


SYMPTOMS. 

Early  History. — The  deformity  of  scoliosis  is  developed  during  the 
growing  years,  becoming  arrested,  as  a  rule,  at  the  end  of  the  period  of 
growth. 

The  affection  is  ordinarily  discovered  by  the  patient's  mother  at 
the  age  just  previous  to  puberty,  although  it  is  developed  earlier  than 
this  in  a  majority  of  cases  without 
being  recognized.  The  symptoms 
are  so  slight  in  the  earliest  stages  and 
the  deformity  is  so  easily  overlooked 
that  the  surgeon  is  rarely  consulted. 
The  patient  suffers  no  inconven- 
ience at  this  stage,  and  as  the  child 
is  at  an  age  (five  to  ten)  when  the 
figure  is  not  carefully  scrutinized, 
little  attention  is  paid  to  the  slight 
elevation  of  the  shoulder  or  projec- 
tion of  the  hip.  Upon  superficial  ex- 
amination but  little  else  is  to  be  seen, 
and  these  symptoms  disappear  on  re- 
cumbency or  suspension.  A  careful 
examination  often  discloses  a  pecul- 
iarity in  standing  or  sitting. 

In  a  majority  of  cases  when  the 
surgeon  is  consulted,  well  marked  de- 
velopment of  the  distortion  has  al- 
ready taken  place,  with  more  or  less 
structural  change. 

The  muscular  system  may  or  may 
not  be  well  developed,  but  in  a  majority  of  cases  the  muscles  are  not 
large  or  strong.  In  the  early  periods  of  the  development  of  the  affec- 
tion there  is  rarely  any  symptom  complained  of  except  the  annoyance 
of  the  curvature,  due  to  a  distortion  of  the  figure.     In  a  few  instances 


Fig.  294. — Front  View  of  Lateral  Curva- 
ture, Showing:  Prominence  of  Left 
Mamma  in  Right  Dorsal  Convex  Curva- 
ture. 


332 


ORTHOPEDIC  SURGERY. 


of  growing  girls  with  marked  impairment  of  strengtii  some  thoracic 
pain  may  be  felt,  and  fatigue  on  exertion  in  walking  or  standing.  The 
period  during  which  the  curvature  of  the  spine  may  develop  is  in- 
definite, as  well  as  are  the  rate  and  extent  of  the  development.     It  is 

impossible,  in  the  present 
stage  of  our  knowledge,  to 
predict  the  amount  of  in- 
crease or  the  permanency 
of  arrest.  The  liability  to 
increase  is  greatest  during 
the  growing  years.  But 
cases  of  severe  curvatures 
will  be  seen  in  which  de- 
velopment has  slowly  con- 
tinued during  the  years  of 
younger  adult  life. 

While  it  is  certainly 
true  that  the  time  when 
a  curve  may  be  regarded 
as  arrested  is  not  easily 
recognized,  an  examina- 
tion of  a  large  number  of 
untreated  cases  justifies 
an  opinion  that  spontane- 
ous arrest  takes  place  in  a 
very  large  number  of  the 
slighter  cases,  without  fur- 
ther development  of  the 
deformity.  Even  in  many 
of  the  severer  types  of  the 
deformity  patients  will  be  observed  who  go  through  adult  life  without 
any  increase  of,  or  inconvenience  from,  the  deformity. 

The  symptoms  of  lateral  curvature  zro.  pain,  impah^fnent  of  general 
condition,  and  deformity. 

Pain. — Painful  symptoms  are  not  common  in  the  affection,  except 
in  the  severest  cases. 

The  symptoms  of  pain  are  of  three  classes : 

I  St.  Those  due  directly  to  the  altered  muscular  or  ligamentous 
strain. 

2d.  Those  due  to  the  abnormal  pressure  from  distorted  ribs  upon. 
the  nerves  or  ilium,  or  by  vertebrae  upon  nerves,  or  to  alteration  of  the 
size  and  shape  of  the  thorax,  and  displacement  of  viscera. 

3d.  Neurasthenic  symptoms  from  a  lack  of  vitality,  superinduced 
by  the  limitations  as  to  exercise  and  activity,  consequent  on  the  deform- 


FlG.  295. — Right  Lateral  Curvature.     (Weigel.) 


LATERAL    CURVATURE   OF   THE  SPINE. 


333 


ity,  and  to  the  impairment  of  circulation  and  res]:iiration  by  the  deform- 
ity of  the  chest. 

Impairment  of  General  Condition. — Interruption  in  the  functions  of 
the  liver,  stomach,  and  intestines  is  occasionally  seen  in  severe  cases. 
Shortness  of  breath  also  occurs,  as  well  as  pain  in  the  stomach,  loss  of 
appetite,  and  indigestion.  In  the  severest  cases  a  lack  of  deposit  of  fat 
in  the  subcutaneous  tissue  will  be  noticed,  and  the  patients  are  thin, 
even  though  they  may  be  in  relatively  good  health. 

Deformity. — The  chief  symptom  of  lateral  curvature  is  the  distor- 
tion.    This,  as  has  been  explained,  is  not  limited  to  a  simple  lateral 


Fig.  296.  — Severe  Lateral  Curvature  (Un- 
treated). 


Fig.  297.— Right  Dorsal,  Slight  Left  Lumbar 
Curve. 


curvature  of  the  spine,  but  to  this  is  added  a  twisting  of  the  trunk ;  or, 
in  other  words,  there  is  both  a  curvature  and  a  rotation  on  a  vertical 
axis. 

The  curves  of  the  spinal  column  vary  in  degree,  situation,  and  ex- 
tent. There  are,  however,  common  types,  which  it  is  convenient  to 
bear  in  mind  in  considering"  the  subject  of  treatment. 

Lateral  curvature  either  involves  the  whole  spine  in  one  curve, 
termed  by  some  writers  total  scoliosis,  or  it  is  chiefly  confined  to  a  re- 
gion or  regions  of  the  spine,  and  the  curvature  is  called  cervical,  dojsa/. 


334 


ORTHOPEDIC  SURGERY. 


or  lumbar  scoliosis.     These  are  defined  right  or  left,  according  to  the 
direction  of  the  convexity  of  the  curves. 

What  is  termed  double  scoliosis  is  met  when  an  upper  curve  is  found 
in  one  direction  and  a  lower  in  the  opposite. 

If  one  lateral  curve  occurs  in  the  middle  region  of  the  spinal  col- 
umn, one  or  two  other  compensating  curves  are  of  necessity  developed 
in  opposite  directions,  to  preserve  the  patient's  balance,  above  or  below 
the  deformity,  in  order  that  the  head  be  kept  erect  and  in  the  median 
line.  These  compensating  curves  may  or  may  not  be  of  pathological 
significance.  In  some  instances  one  of  the  compensating  curves  is  of 
an  equal  prominence  with  the  so-called  primary  curve ;  in  which  case 

the  spinal  column  will  pre- 
sent the  S-shaped  curve 
which  is  characteristic.  In 
other  cases  what  is  termed 
the  compensating  curve  may 
become  more  marked. 

The  curves  are  rarely 
limited  exactly  to  definite 
portions  of  the  spinal  col- 
umn ;  the  upper  curve  may 
be  so  long  as  to  include  all  of 
the  dorsal  and  upper  lumbar 
vertebrae.  Again,  the  lower 
curve  may  be  so  long  as  to 
invade  nearly  the  whole  of 
the  dorsal  region,  the  com- 
pensation taking  place  in  the 
upper  part  of  the  cervical  re- 
gion. 

In  all  varieties  of  curves 
except  the  total,  compensat- 
ing curves,  so  called,  are 
necessarily  present.  They 
may  be  so  slight  as  not  to 
attract  attention. 

Furthermore,  when  the 
curves  are  in  the  flexible 
stage  it  is  difficult  to  de- 
termine which  is  the  more  important  one ;  but  after  osseous  changes 
have  taken  place,  the  most  important  curves  become  fixed,  and  these 
are  the  curves  which  demand  most  attention.  This  is  partly  due  to 
the  attitude  in  which  the  column  is  placed,  and  partly,  probably,  to 
a  lack  of  resistance  of  tissues  of  certain  parts  of  the  spinal  column. 


Fig.  298. — Severe  Right  Dorsal,  Left  Lumbar  Curve 
Showing'  Marked  Lumbar  Rotation  on  the  Left. 


LATERAL    CURVATURE   OF   THE  SPLNE. 


335 


Cervical  Curvature. — The  cervical  or  cervico-dorsal  curves  are  the 
least  common  form  of  lateral  curvature,  except  when  associated  with 
torticollis. 

This  curvature  may,  however,  occur  primarily ;  when  it  does,  it  is 
most  commonly  accompanied  by  a  long  compensatory  lower  curve. 
There  is  invariably  elevation  of  one  shoulder  and  an  inclination  of  the: 
axis  of  the  head  to  the  side  of  the  concavity  of  the  cervical  curve. 

Dorsal  Curvature. — The  most 
common  dorsal  curve  is  with  the 
convexity  to  the  right.  In  these 
cases  the  right  shoulder  will  be 
raised,  the  right  shoulder  blade 
will  project  backward  more  prom- 
inently than  the  left,  and  will  be 
at  a  higher  horizontal  level  and 
farther  from  the  median  line  of 
the  trunk.  The  back,  just  below 
the  scapula,  will  be  more  rounded 
backward  on  the  right  side  and 
more  flattened  on  the  left,  and 
the  left  shoulder  will  be  held 
down.  In  front,  in  well-marked 
cases,  the  breast  and  front  of  the 
chest  may  be  more  prominent  on 
the  left  than  on  the  right  side. 

In  addition  to  the  curve  there 
may  be  a  tendency  to  displace- 
ment of  the  whole  trunk  to  the 
right  side.  When  this  is  the  case, 
the  right  arm,  when  hanging,vvill 
be  free  from  the  side,  while  the 
left  arm,  when  hanging  dovvn, 
necessarily  strikes  the  hip. 

There  is  also,  unavoidably,  a  change  in  the  outline  of  the  sides  of 
the  back.  The  sides,  instead  of  being  symmetrical,  as  seen  from  the 
back,  will  be  different;  one  side  of  the  outline  will  be  unnaturally 
straight,  and  the  other  more  than  normally  hollowed. 

The  normal  backward  physiological  curve  in  the  dorsal  region  may 
be  diminished  so  that  the  upper  back  is  abnormally  fiat,  or  it  may  be 
increased  so  that  the  dorsal  region  is  abnormally  bowed.  The  latter 
condition  is  spoken  of  by  German  writers  as  kyphoskoliose. 

Lumbar  Curvature. — Lumbar  dorsal  or  lumbar  curvature  manifests 
itself  by  a  prominence  of  one  of  the  hips ;  the  one  on  the  side  of  the 
concavity  of  the  curve  appears  in  the  contour  of  the  trunk  higher  than 


Fig.  299. — Right   Dorsal,   Left  Lumbar   Curves 
with  Displacement  of  Body  to  the  Right. 


336 


ORTHOPEDIC  SURGERY. 


on  the  other  side,  as  it  is  less  covered  by  overlying  tissue.  It  is  often 
termed  a  "high  hip,"  but  incorrectly;  measurement  shows  no  differ- 
ence. In  well-marked  lumbar  curvature  there  is  also  a  fulness  in  the 
back  on  the  one  side,  above  the  crest  of  the  ilium,  and  a  corresponding 
flattening  on  the  other.  In  front  the  umbilicus  is  at  the  side  of  the 
median  line.  A  marked  difference  in  the  outlines  of  the  two  sides  of 
the  back,  already  mentioned,  is  seen  in  this  form  of  curvature. 

A  combination  of  lumbar  and  dorsal  curves  in  opposite  directions, 

or  compound  curves  as  they 
have  been  termed,  will  present 
the  features  of  both  varieties, 
but  the  distortion  of  the  most 
pronounced  curve  predomi- 
nates. 

Limping. — In  severe  cases 
of  curves  involving  the  lum- 
bar region  the  distortion  of 
the  vertebral  column  is  so 
great  that  the  pelvis  is  second- 
arily tilted,  and  by  this  one  leg 
is  rendered  shorter  than  the 
other  for  practical  purposes 
and  a  more  or  less  marked 
limp  may  be  caused. 

Structural  and  Postural 
Curves. — Curves  will  be  found 
to  vary  not  only  in  their  local- 
ization and  their  amount  of 
rotation,  but  also  in  their  ri- 
gidity. This  variation  is  due 
to  the  variation  in  the  amount 
of  structural  change.  For 
clinical  purposes  it  is  conveni- 
ent to  apply  the  term  struct iiral 
curves  to  those  with  evident 
changes  in  the  tissues,  and  pos- 
tural to  iho's,^  curves  wdthout  definite  structural  changes.  The  latter 
are  flexible  and  easily  corrected  by  the  patient's  effort,  by  lying  down 
or  by  suspension.  In  the  latter,  rotation  is  not  a  prominent  symptom. 
These  curves  have  also  been  designated  as  fixed  or  habitual.  The 
Xoxvcva  primary  and  secondary  curves  are  also  used  to  define  the  relative 
clinical  importance  or  severity  of  the  two  curves  present.  This  appli- 
cation of  the  term  is  preferable  to  the  use  of  these  terms  to  designate 
the  one  first  formed,  as  it  is  impossible  to  determine  this  in  many  cases. 


Fig.   300.— Left    Total    Curve   Showing    Elevated 
Left  Shoulder. 


LATERAL    CURVATURE   OE   THE  SPLNE. 


337 


Rotation. — As  is  explained  under  the  head  of  pathology,  it  is  impos- 
sible for  any  curvature  to  take  place  in  the  spinal  column  without  being 
accompanied  by  rotation. 

The  prominence  of  rotation  in  lateral  curvature  is  a  measure  of  the 
severity  of  the  case. 

The  amount  of  rotation  may  be  much  greater  in  some  cases  than 
would  be  expected  by  the  slight  amount  of  apparent  lateral  deviation  of 


Fig.  301. — Right  Dorsal  Curvature  Follow- 
ing Empyema  of  the  Left  Side. 


Fig.  302. — Right  Dorsal  Curve,  Showing  Ele- 
vation of  Right  Shoulder,  Prominent  Left 
Hip,  and  R.otation  of  Right  Chest  Back- 
ward. 


the  spinous  processes,  as  if  the  vertebras  yielded  more  by  twisting  under 
superincumbent  weight  than  by  curving  to  the  side. 

Rotation,  as  has  been  shown,  is  always  toward  the  convex  side  of  the 
lateral  curve ;  but  in  childhood  the  so-called  total  scoliosis  often  shows 
a  general  backward  prominence  of  one  side.  The  backward  projecting 
shoulder  will  often  be  found  on  the  concave  rather  than  the  convex 
side.  This  occurs  only  in  a  flexible  spinal  curve,  where  the  compensa- 
tory curve  is  not  easily  recognized  or  entirely  established.  It  is  per- 
haps the  initial  stage  of  the  ordinary  type  of  scoliosis,  the  long  curve 
being  afterward  divided  into  two  sections. 

Relative  Frequency  of  Curves — The  lateral  curvature  most  com- 
22 


338 


ORTHOPEDIC  SURGERY. 


monly  seen  by  the  surgeon  is  the  right  convex  dorsal  curve.  To  this 
is  frequently  added  a  lower  curve  with  the  convexity  to  the  left.  If  the 
■  trunk  is  displaced  to  the  right,  as  is  often  the  case  in  long  dorsal  curves, 
the  left  hip  is  uncovered  and  appears  more  prominent  than  the  right, 
the  reverse  being  the  case  when  the  trunk  is  displaced  to  the  left. 
When  school  children  are  examined  irrespective  of  symptoms  complained 
of,  many  postural  curves  not  brought  to  the  surgeon  for  examination 


Fig.  303. — Lateral  Curvature  Due  to  Empy- 
ema of  Right  Chest.  Five  months  after 
operation. 


Fig.   304.— Congenital   Lateral  Curvature  As- 
sociated with  Absence  of  Ribs. 


are  seen.     Of  these,  total  curves  will  be  found  the  most  common,  and 
of  these,  the  one  with  the  convexity  to  the  left  is  the  most  frequent.' 


VARIETIES   OF    LATERAL   CURVATURE. 

Rhachitic  Lateral  Curvature. — This  form  occurs  in  rhachitic  chil- 
dren, but  it  is  not  so  common  a  curve  as  the  simple  posterior  curve 
which  appears  as  a  backward  prominence  in  the  lumbar  region  in  so 
many  cases  of  rickets.  In  some  varieties  of  lateral  curvature  there 
may  also  be  an  exaggerated  antero-posterior  curve  due  to  yielding  of 

'  Liining  and  Schulthess:  "  Orth.  Chir. ,"  Munich,  1901,  p.  246. — Zeitsch.  f. 
orthopadische  Chir.,  1902,  Bd.  x. 


LATERAL    CURVATURE   OF   THE  SPINE. 


339 


the  bones  under  the  unusual  distribution  of  superincumbent  weight.  It 
is  probable  that  if  cases  with  rickets  were  more  carefully  examined, 
scoliosis  would  be  more  frequently  observed.  Truslow  '  found  it  in  15 
per  cent  of  201  cases  of  lateral  curvature,  and  Mayer"  found  scoliosis 
in  217  out  of  220  rhachitic  children. 

Difference  in  Length  of  Legs. — A  slight  difference  in  the  length 
of  the  lower  limbs  is  the  rule.     But  development  of  lateral  curvature 
directly  from   this  cause  is  not  invariable,  as  is  evident  from  the  fact 
that   in   cases  of  scoliosis  a 
notable    difference     in     the 
length  of  the  lower  limbs  is 
detected,  in  about  the  same 
proportion  of  cases  as  in  nor- 
mal   children.       In   children 
with    marked    inequality   in 
the  length  of  the   legs  and 
with    diminished    resistance 
in  the  vertebral  column,  sco- 
liosis will  follow. 

Paralytic  Lateral  Curva- 
ture.— In  a  certain  number 
of  cases  of  paralysis  of  the 
muscles  of  the  back  lateral 
curvature  of  the  spine  is 
found. 

When  the  muscles  of  the 
back  are  weak,  the  patient 
instinctively  assumes  an  at- 
titude in  which  the  spine  is 
balanced  with  the  least  action 
on  the  part  of  the  weakened 
muscles.  The  curvature  may 
be  toward  the  side  of  the 
paralyzed  muscles  or  away 
from  them.^  The  bones  of 
the  spine  may  be  distorted 
(if  lacking  in  a  power  of  resistance)  by  a  constant  vicious  attitude, 
and  a  fixed  lateral  curvature  result. 

This  form  of  lateral  curvature  is  most  commonly  developed  after 
infantile  paralysis,  as  this  is  the  most  common  form  of  paralysis  occur- 
ring in  the  growing  years ;  but  the  effect  of  other  palsies,  if  influential 

'  Whitman  :  "  Orthopedic  Surgery." 
^Bulletin  Medical,  June  15th,  1901. 
^  Arnd  :  Arch.  f.  Orthopadie,  vol.  i..  No.  i. 


Fig.  305.— Left  Lumbar  Dorsal  Curve. 


340 


ORTHOPEDIC  SURGERY. 


in  weakening  certain  muscles  of  the  back,  would  be  the  same,  and  the 
distortion  may  be  seen  after  spastic  paralysis,  progressive  muscular  hy- 
pertrophy, syringomyelia,  and  other  affections  weakening  the  muscles 
of  the  spinal  column. 

Torticollis. — Affections  causing  unequal  muscular  contraction  of  the 
muscles  of  the  back  will  throw  the  spine  out  of  balance.  In  this  cate- 
gory torticollis  is  to  be  mentioned,  as  lateral  curvature  always  follows 
this  affection  unless  it  is  corrected.     Inequality  of  vision  and  hearing 


Fig.  306.— Severe  Curvature  due  to  Rickets. 

and  congenital  conditions  causing  the  head  to  be  held  to  one  side  (T. 
Dwight)  are  possible  causes  of  scoliosis. 

Lateral  Curvature  from  Contracture  of  the  Chest. — Lateral  curva- 
ture may  follow  empyema,  and  some  deviation  of  the  spinal  column  is 
likely  to  follow  severe  forms  of  empyema.  In  the  purest  forms  of  this 
type  the  spine  is  pulled  to  one  side,  the  ribs  being  flattened,  i.e.,  fixed 
obliquely  at  a  lower  angle  than  normal,  from  the  cicatricial  contrac- 
tion of  the  kmg  which  prevents  expansion  of  the  lung  on  that  side 
and  leads  to  an  increased  expansion  on  the  other.  In  certain  cases 
the  altered  position  so  induced  has  its  effect  upon  the  growth  of  the 
spine. 


LATERAL   CURVATURE  OF   THE  SPINE. 


341 


It  has  been  said  that  a  curvature  followed  in  some  instances  pneu- 
monia, phthisis,  and  organic  heart  disease. 

Lateral  curvature  may  follow  sarcoma  of  the  ribs  and  lung.' 

Lateral  Curvature  from  Occupation. — Any  occupation  which  neces- 
sitates faulty  attitudes  for  long  periods  daily,  favors  the  development  of 
spinal  curve,  but  lateral  curvatures  of  severe  type  due  to  ordinary  oc- 
cupation are  not,  as  a  rule,  common,  for  the  reason  that  laborious  occu- 
pations are  not,  in  general,  entered  upon  until  an  age  when  the  spinal 
column  has  a  sufficient  amount  of  resistance  to  withstand  the  superim- 
posed weight  without  developing  great  structural  change. 

Slight  lateral  curves  may  be  seen,  analogous  to  the  kyphosis  of 
those    employed  in    occupations   requiring  stooping.     In  clerks  one 


Fig.  307. — Severe  Case  of  Spastic  Paralysis  in  a  Patient  who  had  never  Walked  and  who  from 
Childhood  had  Sat  to  One  Side.     The  patient  is  now  an  adult. 

shoulder  is  often  higher  than  the  other  from  the  attitude  of  writing, 
and  it  is  said  to  be  true  also  in  blacksmiths.  Severe  forms  of  this  class 
are  sometimes  seen  in  adolescents  whose  occupation  habitually  twists 
the  spine,  as  in  carrying  baskets  or  trays.' 

Scoliosis  in  nursing  women,  from  carrying  infants  too  frequently 
upon  one  side,  is  also  recorded,  and  the  same  attitude  in  one-armed  per- 
sons. 

Scoliosis  seen  in  school  children  is  in  reality  generally  an  occupa- 
tion deformity,  resulting  as  it  does  from  the  constant  assumption  of 
faulty  attitudes,  which  produce  abnormal  pressure  and  strain  upon 
growing  spinal  columns  lacking  in  structural  resistance. 

Congenital  defects  in    the    spinal  column  with  misshapen  vertebras 

'  Boston  Med.  and  Surgical  Journal,  January  loth,  1889. 
-Zuppinger:  Zeitsch.  f.  orthopadische  Chir. ,  xi.,  p.  280. 


342 


ORTHOPEDIC  SURGERY. 


is  a  cause  of  congenital  deformity,  but  it  is  impossible  in  the  absence 
of  reliable  statistics  to  determine  how  commonly  this  occurs. 

Alteration  in  the  shape  of  the  vertebrcz  from  disease  (Pott's  disease, 
osteomyelitis  of  the  spine,  and  spondylitis  deformans)  may  cause  lateral 
curvature.  It  may  also  occur  in  Pott's  disease  and  sacro-iliac  disease 
as  the  result  of  muscular  spasm. 

Ischias  scoliotica,  referred  to  also  as  scoliosis  neuromuscularis,  or 
neuropathica  or  ischiatica,  is  a  term  which 
has  been  applied  to  lateral  curvature  in  the 
lower  part  of  the  spinal  column  occurring 
in  connection  with  s'^iatica.  It  is  severest 
in  cases  in  which  the  lumbar  nerves  are 
involved.  The  curvature  may  be  to  the  side 
of  the  affected  nerve,  or  the  reverse,  or  it 
may  alternate.  The  condition  is  most  easily 
relieved  by  fixative  appliances. 

DIAGNOSIS. 

A  diagnosis  of  lateral  curvature,  in  a  se- 
vere case,  is  so  simple  that  an  inspection  of 
the  patient  is  all  that  is  required. 

In  the  less-marked  cases,  however,  the 
recognition  of  the  true  nature  of  the  de- 
formity is  not  so  easy,  and  a  careful  examina- 
tion is  necessary,  not  only  for  the  exclusion 
of  other  affections  of  the  spine,  but  also 
for  an  estimate  of  the  progress  of  the  lateral 
curvature  and  the  amount  of  rotation  and 
bony  change  in  the  spinal  column. 

The  method  of  examination  of  a  case  of 
lateral  curvature  is  as  follows : 

The  patient's  back  should  be  bared  in 
ordinary  cases  to  the  level  of  the  trochanters, 
and  the  arms  should  be  allowed  to  hang- 
free.  The  most  natural  attitude  in  standing 
should  be  noted  and  also  the  position  of 
the  patient  in  an  attempt  to  stand  in  as  straight  a  position  as  is  pos- 
sible ;  the  tips  of  the  spinous  processes  are  to  be  marked  with  a  skin 
pencil,  and  also  the  ends  of  the  scapulae.  To  determine  the  central 
line  a  string,  to  which  a  slight  weight  is  attached,  is  hung  from  the  sev- 
enth cervical  vertebra  (to  w^hich  it  can  be  fixed  by  a  piece  of  adhesive 
plaster),  the  string  being  long  enough  to  hang  below  the  cleft  of  the 
buttock ;  or  the  string  should  be  used  as  a  plumbline  to  show  a  perpen- 
dicular, erected  from  the  middle  of  the  pelvis.     In  this  case  it  hangs  in 


Fig.  308.— Lateral  Curvature  due 
to  Infantile  Paralysis  of  Mus- 
cles of  Trunk. 


LATERAL    CURVATURE   OF    THE  SPLNE.  343 

the  cleft  of  the  buttock,  and  the  deviation  of  the  spine  from  this  verti- 
cal line  can  be  noted.  The  distance  of  the  tips  of  the  scapulae  (the 
arms  being  crossed  in  front  of  the  chest)  from  this  central  line  should 
be  measured,  and  also  the  distances  from  this  line  to  the  points  of 
greatest  curvature  of  the  line  of  the  spinous  process.  These  points  be- 
ing noted,  the  slope  of  the  shoulders,  the  outlines  of  the  sides  of  the 
trunk,  and  the  contour  of  the  back,  as  well  as  any  lack  of  symmetry  or 
unilateral  fulness,  should  be  carefully  recorded,  both  when  the  patient 
is  standing  and  in  the  stooping  position,  with  the  back  well  arched.  If 
a  side  deviation  of  the  line  of  the  spinous  processes  is  observed,  a  lack 
of  symmetry  of  outline,  or  a  unilateral  projection  of  the  ribs  or  scapulae, 
in  the  erect  position,  it  should  be  recorded  and  the  patient  should  be 
suspended  by  means  of  a  head  sling  and  also  made  to  lie  in  a  recum- 
bent position  upon  the  face.  A  marked  alteration  of  the  curvature, 
contour,  or  outlines  following  removal  of  the  superincumbent  weight  is 
of  particular  importance. 

If  the  curve  disappears  under  these  conditions,  it  is  to  be  classed  as 
postural.     If  it  does  not  disappear,  it  is  to  be  considered  structural. 

The  patient  should  then  bend  forward  with  the  knees  straight  and 
the  arms  hanging  until  the  trunk  is  horizontal.  In  the  normal  spine 
the  two  sides  of  the  back  will  be  on  a  level  when  viewed  in  this  posi- 
tion. Rotation  of  the  ribs  or  lumbar  vertebrae  due  to  structural 
changes  is  shown  by  a  greater  upward  prominence  of  the  side  of  the 
back  which  has  rotated  backward.  This  may  be  measured,  if  desired, 
by  a  plumbline  hanging  from  the  angle  between  the  arms  of  a  pair  of 
calipers.  This  plumbline  records  the  variation  from  the  horizontal  in 
a  protractor  fastened  at  the  angle  of  the  calipers,  or  the  apparatus 
(^Nivclliertrapez)  of  Schulthess '  may  be  used  for  the  same  purpose. 

The  flexibility  of  the  spine  should  be  tested  by  causing  the  patient 
to  stand  first  with  one  foot  and  then  the  other  upon  a  series  of  blocks 
half  an  inch  in  thickness,  and  testing  what  height  can  be  placed  under 
the  patient's  foot  without  preventing  her  from  standing  upon  both  legs 
with  the  limbs  straight,  without  flexion  at  the  knee;  this  tests  the  lat- 
eral flexibility  in  the  lower  part  of  the  spinal  column.  In  testing  the 
flexibility  higher  up,  the  patient  should  be  seated  on  a  stool,  and  one 
hand  of  an  assistant  be  placed  upon  her  side,  above  the  crest  of  the 
ilium,  while  the  other  hand  should  be  placed  upon  the  crest  of  the 
ilium  of  the  opposite  side.  The  patient  should  then  be  directed  to 
bend  sideways  toward  the  side  of  the  higher  hand,  and  the  amount  of 
this  motion,  without  tilting  of  the  pelvis,  is  to  be  noted. 

The  lateral  flexibility  can  also  be  readily  seen  by  directing  the  pa- 
tient to  bend  to  the  side  with  the  hands  behind  the  head  and  the  feet 
apart,  keeping  the  legs  straight  and  avoiding  twisting  the  pelvis. 
'  Liining  and  Schulthess:  "  Orth.  Chir  ,"  jMiinchen,  1901,  p   153. 


344 


OR  THOPEDIC  S  UR  G  ER  \  \ 


It  is  not  always  necessary  to  examine  the  front  of  tlie  patient's 
trunk  in  the  case  of  older  patients.  When  this  is  done,  the  projection 
of  the  ribs  in  front,  and  the  difference  in  the  prominence  or  flatness  of 
the  two  breasts,  the  deviation  of  the  tip  of  the  sternum  and  of  the  um- 
bilicus from  the  median  line  are  of  importance,  as  indicating  the  amount 
of  structural  change  which  has  taken  place.  The  asymmetry  of  outline 
is  always  to  be  more  clearly  seen  from  the  front  than  from  the  back  of 
the  patient. 

The  strength  of  the  muscles  of  the  patient's  back  may  be  tested,  if 
desired,  by  means  of  a  dynamometer,  or  spring  balance,  and  the  height 
and  weight  should  be  recorded  and  compared  with  the  normal  standard 
for  the  age  as  given. 

A  diagnosis  of  lateral  curvature  in  the  early  stage  is  to  be  made  by 


Fig.  309.— Measurement  of  the  Rotation  of  the  Ribs  in  the  Horizontal  Position  \iy  the  Levelling 
Trapezium  of  Schulthess.     (Schulthess.) 

observing  in  any  case  an  habitual  lack  of  symmetry  in  the  outline  of 
the  sides  of  the  trunk  and  the  slope  of  the  shoulders,  in  the  unnatural 
projection  of  one  shoulder  blade  or  a  portion  of  the  trunk  on  one  side 
or  of  one  hip,  and  on  a  constant  deviation  of  the  line  of  the  spinous 
processes  from  the  vertical  line. 

The  accidental  assumption  of  a  faulty  attitude  does  not  justify  a  diag- 
nosis of  lateral  curvature ;  but  the  habitual  assumption  of  such  a  posi- 
tion, when  the  patient  stands  in  the  attitude  of  ease  and  greatest  com- 
fort, indicates  an  abnormal  condition.  The  existence  of  slight  grades 
of  lateral  curvature  is  made  more  evident  by  allowing  the  patient  to 
stand  for  a  minute  before  beginning  the  examination,  in  order  to  obtain 
the  relaxed  position  due  to  beginning  muscular  fatigue. 

The  amount  of  structural  change  is  indicated  by  the  amount  of  stiff- 
ness and  by  the  slight  change  in  the  curves  and  asymmetrical  symptoms 


LATERAL    CURVATURE   OF   THE  SPINE. 


1  A   r" 


as  the  patient  alters  the  position  by  standing,  lying,  bending,  twisting, 
and  hanging.  In  this  way  it  is  possible  to  determine  the  amount  of 
progress  the  distortion  has  made  and  the  stage  of  the  affection. 

Lateral  curvature  is  not  infrequently  confounded  with  Pott's  disease 
through  ignorance  of  the  nature  of  either  affection,  both  being  classed 
as  chronic  spinal  affections.  In  pro- 
nounced lateral  curvature,  the  lateral 
twist  and  the  rotation  are  essentially 
different  from  the  curve  of  Pott's  dis- 
ease, w^hich  is  chiefly  an  antero-pos- 
terior  curve.  In  the  former,  rotation 
is  an  unmistakable  symptom ;  in  the 
latter,  it  is  absent  or  slight.  In  the 
slighter  cases  of  lateral  curvature  the 
spine  is  flexible  and  the  lateral  curve 
diminishes  or  disappears  on  recum- 
bency ;  and  there  is  never  a  sharp  angu- 
lar projection.  In  Pott's  disease  the 
spine  is  not  flexible  but  stiff,  the  curve 
is  angular,  and  it  does  not  disappear 
on  recumbency.  Lateral  curvature  oft- 
en exists  in  Pott's  disease,  but  is  a  lean- 
ing of  the  whole  body  to  one  side  and 
is  associated  with  the  signs  of  destruc- 
tive disease. 

Methods  of  Recording  Lateral 
Curvature. 

For  clinical  purposes  a  careful  record 
of  lateral  curvature  is  necessary. 

In  recording  lateral  curvature  it  is 
desirable  to  note  the  flexibility  of  the 
spine,  the  curve,  and  the  amount  of  twist 
or  rotation,  as  well  as  the  attitude  and 
contour.  Photography,  if  carefully  em- 
ployed, is  of  assistance.'  For  this  pur- 
pose the  spinous  processes  should  be 
marked;  and  a  line  drawn  from  the  sev- 
enth cervical  spine  to  the  cleft  of  the 
buttocks,  which  marks  the  median  line  of  the  body.  The  patient  if 
standing  should  be  placed  squarely  before  a  camera  and  photographed 
with  an  arrangement  of  light  to  prevent  strong  shadows.  The  rotation 
can  be  photographed  if  the  standing  patient  stoops  and  the  camera  is 
'  Spelissy :  Trans.  Am.  Orth.  Assn.,  vol.  xv. 


Fig.   310. — Apparatus    for    Recording' 
Lateral  Curvature.     (Feiss.) 


346 


ORTHOPEDIC  SURGERY. 


focussed  on  the  portion  of  the  back  showing  the  greatest  rotation  of 
the  spine. 

A  more  ready  but  less  reUable  means  of  record  can  be  furnished  by 
the  following  measurements  made  and  recorded  from  the  spinous  proc- 
esses to  the  line  connecting  the  two  ends  of  the  spine :  First,  the  dis- 
tances between  the  line  from  the  seventh  cervical  spine  to  the  cleft 
of  the  buttock  and  the  points  of  maximum  curve  of  the  line  of  the 
spines  in  the  upper  and  lower  curve  if  both  exist  are  recorded ;  second, 
the  distance  from  the  spine  of  the  seventh  cervical  vertebra  to  the 
point  where  the  line  connecting  the  ends  of  the  spine  crosses  the  line 
of  curve. 

A  simple  apparatus  devised  by  H.  O.  Feiss,  of  Cleveland,  gives  a 
fairly  accurate  record  of  the  deformity  by  means  of  series  of  horizontal 


Ltanf.Su/t.s/tiney 


f/ 


Bf.  anisu/t.spme 


iter 


J^^ 


n 

\\ 

s 

Fig.  311.— Tracings  of  a  Case.  The  unbroken  line  representing  the  tracings  at  the  level  of  the 
anterior  superior  spines  and  the  broken  line  the  tracing  at  the  level  of  the  tenth  dorsal 
vertebra.     (Feiss.) 

tracings  of  the  trunk  at  different  levels,  superimposed  on  each  other  in 
a  constant  relation  to  the  median  plane  of  the  body.  The  patient 
stands  on  a  platform,  from  the  back  of  which  projects  a  square,  vertical 
•  upright,  upon  which  slides  a  horizontal  arm  carrying  at  its  ends  two 
horizontal  arms  projecting  forward.  The  patient  stands  back  to  the 
upright,  and  one  horizontal  arm  is  behind  him  and  one  is  on  each  side. 
The  anterior  superior  spines  are  marked  by  a  pencil.  By  means  of 
holes  in  these  arms,  through  which  a  skin  pencil  can  be  inserted,  three 
marks  on  the  patient's  skin  are  now  made  at  the  level  of  the  anterior 
superior  spines,  one  on  the  patient's  back  and  one  on  each  side.  The 
upright  is  then  pushed  up  to  the  level  of  the  greatest  deformity,  and  by 
using  the  same  holes  in  the  uprights  three  more  marks  are  made  on 


LATERAL    CURVATURE   OF   THE  SPINE. 


347 


the  skin  in  the  same  vertical  planes  as  the  others.  Points  are  marked 
in  the  same  way  at  other  levels  if  desired.  Horizontal  contour  tracings 
of  the  back  and  front  of  the  patient  at  the  levels  of  the  marked  points 
are  made  by  means  of  a  "draughtsman's  adjustable  rule."  The  poste- 
rior lower  tracing  is  taken  first  and  the  points  on  the  skin  are  marked  on 
the  tracer,  and  this  tracing  is  reproduced  on  paper ;  the  anterior  part  of 


W    28  20 


-19 
12 

-2* 


Fig.  312.— Apparatus  for  Recording  Lateral  Curvature.  This  machine  records  the  antero- 
posterior curves,  the  line  of  the  spine  and  outline  of  the  body  in  the  lateral  plane  and  the 
horizontal  contour  of  the  back  at  any  level.     (Schulthess.) 


the  tracing  is  then  taken  and  laid  out  on  the  paper.  The  anterior  and 
transverse  lines  of  the  apparatus  are  represented  by  lines  drawn  by  a 
T-square.  The  second  tracing  is  taken  in  the  same  way  and  drawn 
upon  the  paper,  the  marked  points  being  made  to  lie  over  the  same 
points  in  the  first  tracing  drawn.     A  series  of  tracings  is  thus  graphi- 


348  ORTHOPEDIC  SURGERY. 

cally  recorded,  which  bear  the  same  relation  to  each  other  as  the  con- 
tours of  the  patient  do  at  the  recorded  levels.' 

Records  taken  in  this  way  will  serve  for  clinical  purposes,  but  they 
lack  scientific  precision,  as  the  possibilities  of  error  on  the  part  of  the 
recorder  are  too  great  to  be  neglected.  The  methods  answer  for. the 
use  of  a  single  observer,  but  not  for  a  comparison  of  results  in  the  prac- 
tice of  different  surgeons. 

The  best  and  most  accurate  method  of  record  is  that  to  be  obtained 
by  the  apparatus  of  Schulthess.  The  patient  stands  in  a  frame  with 
the  pelvis  secured,  and,  by  means  of  a  pantagraph  working  from  a 
bridge  sliding  up  and  down  in  the  frame,  an  accurate  record  of  the  lat- 
eral deviation  of  the  spinous  processes,  the  antero-posterior  curve  of  the 
spine,  and  the  amount  of  rotation  at  different  levels  is  obtained.  The 
apparatus  is  expensive  and  complicated." 

PROGNOSIS. 

Two  errors  in  prognosis  are  common.  First,  that  the  disease  is  of 
the  most  serious  nature ;  second,  that  it  is  a  trivial  affection  and  will 
be  readily  outgrown  by  the  patient.  The  fact  is,  that  in  the  larger 
number  of  these  cases  the  affection  is  a  self-limited  one,  occasioning 
slight  deformity,  which  persists  through  life,  causing  no  trouble  and 
recognized  only  by  the  dressmaker  or  by  some  near  relative. 

In  other  cases,  however,  the  disease  becomes  decidedly  worse  as  the 
deformity  increases,  and  a  pitiable  distortion  follows,  causing  a  marked 
deformity  and  perhaps  neuralgic  pain. 

It  is  impossible  to  state  positively  in  what  instances  an  increase  of 
the  curve  will  take  place  and  when  they  can  be  relied  upon  to  remain 
stationary.  It  may,  however,  be  said  that  when  the  physical  condition 
during  the  growing  period  remains  constantly  below  the  proper  stand- 
ard, and  when  the  patient's  growth  is  rapid,  an  increase  of  curve  is  to 
be  apprehended.  The  decrease  or  diminution  of  lateral  curvature  from 
simple  growth  without  treatment  is  not  to  be  expected. 

Sometimes  the  disease  may  remain  to  a  slight  extent  during  girl- 
hood and  early  womanhood,  developing  an  increase  at  a  period  past 
middle  life.  Such  cases  are  dependent  upon  a  loss  of  general  health 
•and  upon  trophic  changes  occurring  at  this  period  of  life. 

In  determining  the  prognosis  the  probable  rate  of  growth  is  to  be 
borne  in  mind. 

This  can  be  ascertained  by  the  patient's  height,  the  hereditary  ten- 
dency toward  height  as  ascertained  by  the  height  of  the  parents  and 
the  parents'  families.  The  general  opinion  is  that  completion  of  growth 
exerts  a  powerful  influence  in  arresting  progress  of  the  curvature. 

'H.  O.  Feiss :  Boston  Med.  and  Surg.  Journ  ,  1905. 

-  Liining  and  Schulthess:  "  Orthop.  Chir.,"  Miinchen,  1901,  p.  147. 


LATERAL    CURVATURE   OF   THE  SPINE. 


349 


In  general  it  may  be  said  that  if  a  patient  has  gained  full  height  and 
development  in  figure,  any  increase  in  growth  is  not  often  to  be  ex- 
pected, and  that  an  increase  in  curve  is  not  probable  after  the  osseous 
system  has  become  thoroughly  formed  and  the  strength  of  the  spinal 
column  established. 

The  normal  height  and  weight  of  male  and  female  are  here  given 
for  the  sake  of  reference. 

Table  of  Height  and  Weight  of  the  Human  Body. 

Male. 


Aa-e. 


At  birth 

1  year 

2  years 

3  ■' 

4  " 

5  " 

6  " 

7  " 

8  " 

9  " 
lo      " 

12         " 

14  " 
i6  " 
i8      " 

20  " 
25  " 

30    " 

40   " 


Height  in  Feet  and  Inciies. 


I  ft. 


in.  (o, 

"  (o, 
"  (o, 
"  (o 


6 
10 

3 
6 
8 
9 
9 
8 


496  m. 
696  ^' 

797  " 
860  ■' 

932  " 
990" 
046  " 
112  ■' 
170  " 
227  " 
282  " 

359" 
487" 
610  " 
700  " 

711  " 

,722  " 
722  " 
713  " 


Weight. 


lbs. 


29 

33 

36 

39 

44 

49 

53 

57 

68 

89 

117 

135 

143 

150 

152 
151 


(  3  20 
(10  00 
( 1 2 . 00 
(13  21 

(15  07 
(16.70 
(18.04 
(20.16 
(22.26 
(24.09 
(26  12 
(31  00 
(40.50 
(53 


(61 

(65 
(68 
(68 
(68 


Female. 


Age. 


At  birth 

1  year  , 

2  years 

3 

4 

5 
6 

7 
8 

9 
10 
12 

14 
16 
18 
20 

25 
30 
40 


Height  in  Feet  and  Inches. 


ft. 


6  in.  (0.483  m, 

3  "  (0.690  " 

6  "  (0.780  " 
9"  (0.850" 

. .  .(0.910  " 
2  "  (o  974  •' 

4  "  (I  032  " 

7  "  (1.096  " 
(I. 


4 

9 

II 


139 
200 
248 

327 
447 
500 
562 
570 
577 
579 
555 


Weight. 


6 

20 
25 
27 
31 
34 
37 
40 

43 
50 
53 
67 
84 
98 

"7 
120 
121 
121 
129 


lbs. 


(  2.91  kgm, 

(  9-30  •' 

(11.40  " 

(12.45  " 

(14.18  " 

(15  50  " 

(16.74  '• 

(18.45  " 

(19  82  '' 

(22  44  " 

(24.24  " 

(30  54  '■ 

(38  10  " 

(44.44  " 

(5310  " 

(54  46  " 

(55. oS  ■' 

(55  14  " 

(58. 45  " 


350 


ORTHOPEDIC  SURGERY. 


Prognosis  under  Treatment. 

Theoretically,  lateral  curvature  is  a  deformity  which  can  not  only  be 
prevented,  but  if  treated  in  time  can  be  cured.  Practically,  cases  are 
often  brought  to  the  surgeon  after  structural  changes  have  taken  place 
and  the  tissues  have  become  resistant.  They  are  often  in  the  condition 
of  cases  of  humpback  after  a  cure  has  been  established  with  a  persis- 
tent deformity,  ,when  a  complete  rec- 
tification of  the  curve  is  not  advisable 
on  account  of  the  severity  of  the 
treatment.  If  cases  of  scoliosis  have 
little  structural  change,  improvement 
can  always  be  obtained,  and  often  this 
can  be  made  a  permanent  cure.  In 
cases  wdth  evident  structural  change 
in  the  growing  years,  diminution  of 
the  curve  is  to  be  expected  to  follow 
thorough  treatment.  In  rigid  cases 
an  improvement  of  condition  and  car- 
riage can  be  hoped  for.  The  pros- 
pects of  treatment  are,  of  course, 
better  when  it  can  be  carried  on  dur- 
ing the  period  of  growth. 


Fig.  313. — A  Record  Made  by  the  Machine 
Shown  in  Fig.  312.  At  the  left  is  the 
outline  of  the  upright  spine.  Below  are 
the  contours  of  the  back  at  three  dif- 
ferent levels.     (Schulthess. ) 


PREVENTIVE    MEASURES. 


As  faulty  attitudes  exert  an  in- 
fluence in  causing  lateral  curvatures, 
the  avoidance  of  these  is  of  importance  in  preventing  curves. 

Attitude  at  School. — The  attitude  assumed  dur;ng  school  w^ork  de- 
serves careful  consideration,  as  the  injurious  effect  of  improper  attitude 
has  been  proved  by  statistics  which  show  the  prevalence  of  curvature 
among  school  children,  and  by  the  increase  of  the  deformity  in  school 
years.'  The  prevalence  of  faulty  attitudes  in  school  has  been  shown 
by  Scudder"  and  others.  In  an  examination  of  the  attitudes  of  1,484 
school  children  seated  in  the  schools  of  Boston  and  its  neighborhood, 
sixty-seven  per  cent  were  found  to  be  in  incorrect  position  at  the  time 
of  observation.^ 

An  examination  of  the  attitude  assumed  in  waiting  by  sixty-seven 
healthy  adult  males,  while  writing  in  a  three-hour  w^ritten  examination, 

'Scholder:  "  Schuleskoliosis."  Archiv  f.  ortliop.  Chir.,  i.,  2.— Freeman  :  Ar- 
chives of  Pediatrics,  June,  1904 

-Report  Boston  School  House  Dept. .  1904. 
^  L.  M.  Towne  :  "  Physical  Education  Review." 


LATERAL   CURVATURE   OF   THE  SPINE. 


351 


y 


t 


\ 
J* 


showed  at  the  end  of  two  hours  that  in  all  the  paper  was  inclined 
slightly,  so  that  the  written  line  formed  an  angle  with  the  cross  axis  of 
the  thorax.  This  angle  varied  from  ten  degrees  to  a  right  angle.  The 
inclination  of  the  paper  was  always  such  that  the  right  upper  corner 
was  in  front  of  the  left.  In  a  large  majority  of  the  writers  the  left  side 
of  the  hip  was  in  front  of  the  right,  the  left  shoulder  in  front  of  the 
right,  but  the  left  ear  Avas  usually  slightly  lower  than  the  right  and 
somewhat  behind  it.  .In  all  cases,  therefore,  there  was  a  slight  rotation 
of  the  spinal  column.  The  trunk  in  three-fourths  of  the  writers  was 
inclined  to  the  left,  in  about  one-quarter  to  the  right,  and  in  the  re- 
mainder it  was  held  erect.  It  may  be  fairly  assumed  that,  if  a  twist  of 
the  spinal  column  is  invariable  in  writing  in  strong  men,  faulty  atti- 
tudes will  be  equally  common  in  weakly  children. 

School  Furniture. 

In  the  prevention  of  scoliosis  proper  school  furniture  is  essential. 

Seats. — Chairs  used  by  children  rarely  support  the  back  muscles 
adequately,  which  may  be  unduly  stretched  and  thereby  weakened. 
Children  often  assume  faulty  attitudes  simply  for  the  reason  that  proper 
support  is  not  furnished  the  lower 
part  of  the  back.  They  are  apt  to 
sit  sideways,  the  trunk  being  sup- 
ported on  one  tuberosity  of  the  is- 
chium. The  seat  of  the  chair  in 
which  the  child  is  to  sit  for  any 
length  of  time  should  not  be  deeper 
than  the  length  of  the  thighs  or 
higher  than  the  length  of  the  legs ; 
its  back  should  not  be  above  the 
shoulders  and  should  be  arched  so 
as  to  fit  in  the  hollow  of  the  back. 

If  this  is  not  done,  the  large 
muscles  of  the  back  will  be  unduly 
strained,  as  they  are  inserted  into 
the  broad  fascia  which  is  attached 
to  the  sacrum  and  iliac  bones,  and 

faulty  attitudes  will  be  instinctively    fig.  3i4.-Diagram  of  the  Adjustable  School 

assumed  by  the  patient.  This  is  'iSt!:^^^ ^ Tc^^ ""°°"°''" 
shown  if  tracings  be  taken  of  the 

back  of  a  child  in  the  various  attitudes  of  sitting,  leaning  forward,  back- 
ward, and  sitting  unsupported. 

The  back  of  the  chair  should  slope  backward  slightly,  forming  an 
angle  of  100°  to  110°  with  the  seat.  The  back  of  the  chair  should  be 
arched  with  the  convexity  forward,  the  greatest  convexity  correspond- 


i 


352  ORTHOPEDIC  SURGERY. 

ing  to  the  physiological  curve  in  the  hollow  of  the  back.  The  back  of 
the  chair  should  be  constructed  so  that  it  will  serve  as  a  support  to  the 
spine  when  the  child  leans  backward,  and  especially  to  that  portion  of 
the  back  which  is  in  most  need  of  support  and  subject  to  the  greatest 
strain,  i.e.,  the  lumbar  region.  The  backs  of  most  chairs  simply  touch 
the  shoulders  of  children  in  the  upper  dorsal  region. 

The  following  measurements  are  adapted  from  Staffel:' 

I.  II.  III.         IV. 

6-9  9-12  12-15  Adult, 

years.  years.  years. 

Height  from  seat  to  floor 33  cm.       37  cm.       41cm.       47  cm. 

Height  from  seat  to  middle  of  lumbar  pro- 
jection of  chair 21    "         23    "         25    "  27    " 

From  edge  of  seat  to  vertical  line  drawn  from 

lumbar  projection  to  seat 26    "         30    "         34    "  3S    " 

The  writing-table  should  be  at  a  height  proportionate  to  the  height 
of  the  person  sitting.     The  distance  from  the  top  of  the  seat  to  the  top 


Fig.  315 


-School-room  Fitted  with  Adjustable  School    Chair   in  Use    in   the  Newer  Boston 
Schools.     (Report  of  Boston  Schoolhouse  Commission,  1904.) 


of  the  table  should  be  one-eighth  of  the  height  of  a  girl,  and  one-seventh 
of  that  of  a  boy.  The  height  can  also  be  determined  in  the  following 
ready  way :  The  distance  from  the  olecranon  of  the  bent  arm  to  the 
seat  with  two  inches  added  should  be  the  distance  from  the  seat  to  the 
top  of  the  desk.  The  edge  of  the  table  should  be  just  over  the  edge  of 
the  chair.  The  inclination  of  the  top  of  the  desk  should  be  a  slope  of 
two  inches  in  a  breadth  of  twelve.  Adjustable  school  furniture  is  of 
1  Staffel:  Centralblatt  f.  orthop.  Chir.,  May  ist,  1SS5. 


LATERAL    CURVATURE  OF   THE  SPINE. 


353 


great  importance  in  furnishing  to  school  children  suitable  desks  and 
seats. 

The  chair  adopted  by  the  Boston  School  Commission  after  experi- 
mentation and  measurement,  and  adopted  for  use  in  1903  in  all  new 
and  refitted  school-rooms,  is  one  meeting  most  of  the  requirements  and 
one  which  has  proved  practically  of  use.' 

A  chair  furnishing  support  to  the  back  and  permitting  a  change  of 
position  without  loss  of  support  has  been  devised  by  Professor  Miller 
of  the  Massachusetts  Institute  of  Technology  and  Dr.  Stone,  of  Boston.'.. 

Attitude  in  "Writing. — That  the  development  of  scoliosis  may  be 
influenced  by  a  twisted  attitude  in  writing  would  appear  from  the  dif- 


FiG.  316.— School-room  Shown  in  Fig.  315,  Showing  Scholars  Seated.     Cl'ieport  of  Boston 
Schoolhouse  Commission,  1904.) 

ferent  percentage  of  spinal  curvatures  found  in  different  schools  in  dif- 
ferent cities,  where  the  oblique  and  vertical  writing  are  taught :  ^ 

Oblique  Writing.  Vertical  Writing. 

Per  cent.  Per  cent. 

Nuremberg 24  15 

Zurich 32  12 

Munich 24  15 

Furth.. 65  31 

Wurzburg 28  8 

Although  too  much  credence  can  easily  be  given  to  statistics  with 

'  Reports  of  Boston  School  Commission,  1903  and  1904. 
-'Trans.  Amer.  Orthopedic  Assn.,  vol.  xii. 

■^  Schulthess :     "School     Scoliosis,"    Hamburg,     1903.  — Scholder :     Arch.    f. 
orthop.  Chir. ,  i.,  3. 
23 


354  ORTHOPEDIC  SURGERY. 

such  variation  of  percentages,  it  would  appear  to  be  probable  that  in 
oblique  writing  especial  pains  will  be  needed  to  prevent  a  twisted  atti- 
tude in  writing. 

The  proper  attitude  during  writing  is  with  the  transverse  axis  of 
the  trunk  parallel  with  the  edge  of  the  writing  table.  The  forearms 
should  rest  at  least  two-thirds  of  their  length  upon  the  table.  The 
trunk  should  be  held  erect,  the  legs  should  be  straight  before  the  trunk. 

School  Hygiene  and  School  Gymnastics — ^Proper  lighting  of  school- 
rooms and  the  correct  placing  of  blackboards  are  essential  in  favoring 
proper  attitudes.  The  avoidance  of  long  sitting  periods  by  introducing 
gymnastic  exercises  and  changes  of  position  is  of  importance.'  It  is 
evident  that  gymnastic  exercises  are  of  little  benefit  if  not  carefully 
and  efficiently  supervised. 

Correct  Carriage. — Faulty  attitudes  are  frequently  assumed  in  walk- 
ing and  in  standing,  especially  by  young  children.  The  inclination  to 
stand  upon  one  leg  is  usually  a  habit,  but  in  some  cases  it  may  be  due 
to  a  muscular  weakness  of  one  limb  or  of  a  knee  or  ankle.  The  habit 
is  to  be  corrected  by  drill  or  by  muscular  exercise,  and  by  encourag- 
ing activity  with  the  necessary  constant  change  of  position.  Incorrect 
habits  in  sitting  at  home  are  to  be  remedied  by  insisting  that  the  chil- 
dren with  curvature  shall  not  sit  curled  up  or  bent  over  in  reading,  but 
that  they  shall  sit  in  suitable  chairs  and  hold  the  book  correctly. 

Attitude  during  Sleep. — The  most  common  attitude  in  sleep  is  upon 
the  side,  but  decubitus  upon  the  back  is  more  common  than  on  either 
single  side.  The  right  side  is  more  commonly  lain  on  than  the  left,  but 
the  difference  is  slight ;  young  children  and  men  not  infrequently  lie 
upon  the  belly,  but  the  attitude  is  not  assumed  by  women  or  growing 
girls. 

The  fact  that  a  right-sided  decubitus  is  to  be  avoided  in  a  right  dor- 
sal convex  curve  makes  these  facts  of  value. 

In  ordinary  cases  the  precautions  at  night  which  should  be  observed 
are  that  the  patient  should  not  be  allowed  to  sleep  with  many  pillows 
and  that  the  bed  should  be  a  firm  one.  The  child  should  not  be  al- 
lowed to  assume  a  twisted  position,  but  should  lie  upon  the  back  or  the 
side  of  the  greatest  concavity.  In  threatening  cases  measures  are  nec- 
essary to  preserve  a  proper  position.  This  can  be  done  by  means  of 
bed  frames,  described  under  Pott's  disease. 

Proper  Clothing. — Much  has  been  said  about  the  injurious  effects  of 
corsets,  and  there  is  no  doubt  that  the  muscles  of  the  trunk  are  weak- 
ened by  the  wearing  of  them.'  The  injury  from  compression  may  be 
made  less  by  elastic  lacings  and  by  the  use  of  waists  instead  of  corsets. 

'Report  National  Committee  on  Education,  Washington,  1S94-95,  p.  449-  — 
Ibid.,  1S95-96,  p.  1 174. 

-Hutchinson:  New  York  Medical  Record,  April  27th,  1S89,  p.  464. 


LATERAL    CURVATURE   OF   THE  SPINE.  355 

That  growing  girls  should  be  furnished  with  clothing  which  does  not 
constrict  the  trunk  needs  no  argument.  The  use  of  side  garters,  which 
fasten  tightly  drawn  long  stockings  to  waists  dragging  upon  shoulder 
straps  and  shoulders,  is  to  be  avoided.  This  can  be  done  by  the  use  of 
round  garters  or  attaching  the  garters  to  properly  constructed  .shoulder 
straps  independent  of  the  waist  and  designed  to  draw  the  shoulders 
backward  and  not  forward.  Heavy  petticoats  should  not  be  attached 
to  waists  with  shoulder  straps  dragging  upon  the  shoulders  of  growing 
girls.  This  can  be  avoided  by  the  use  of  union  suits  for  underwear  and 
light  petticoats. 

TREATMENT. 

Several  difficulties  are  to  be  met  in  treating  lateral  curvature.  As 
the  affection  is  active  during  the  period  of  growth,  treatment,  to  be 
efficient,  must  be  carried  on  for  a  long  time,  and  is  tedious  to  the  sur- 
geon and  irksome  to  the  patient.  Furthermore,  as  the  disease  is  one 
that  does  not  threaten  life  and  is  slow  and  uncertain  in  its  outcome,  it  is 
sometimes  difficult  to  enforce  the  proper  treatment  for  the  requisite 
length  of  time.  Again,  danger  of  increasing  deformity  varies  at  differ- 
ent periods  of  the  trouble,  and  consequently  methods  which  are  neces- 
sary at  certain  stages  of  the  affection  are  not  needed  at  others.  Cases 
will  be  brought  to  the  surgeon's  care  presenting  varying  degrees  of 
deformity  and  needing  different  grades  of  treatment.  Cases,  how- 
ever, can  be  grouped  in  two  classes : 

I.  Those  with  slight  structural  change  and  curves  in  the  main  flexi- 
ble. The  treatment  of  this  class  is  directed  to  improving  the  patient's 
attitude,  in  the  expectation  that  if  faulty  attitudes  are  rarely  or  never 
assumed  there  will  be  no  danger  of  an  increase  in  the  structural  changes 
of  the  curve.  The  treatment  is  e.\i\\&r postural,  directed  to  the  forming 
of  correct  habitual  attitudes ;  or  gymnastic,  directed  to  strengthening 
weak  muscles  and  thereby  favoring  correct  carriage. 

II.  Those  with  structural  change  and  curves  which  are  fixed.  In 
these  cases  corrective  treatment  is  directed  primarily  toward  correcting 
existing  curves. 

I.  Treatment  of  Flexible  Cases. 

Postural  Treatment. — The  postural  treatment  consists  in  the  cor- 
rection of  faulty  habits,  the  development  of  weak  muscles,  and  the  re- 
tention of  proper  attitudes.  As  a  raw  recruit  is  taught  the  position 
and  carriage  of  the  soldier,  so  children,  if  faulty  habits  of  attitude  are 
present,  are  to  be  drilled  into  standing  and  walking  in  correct  attitudes. 
This  method  is  suited  for  the  simplest  cases  of  beginning  curvature. 
To  be  thoroughly  carried  out,  it  requires  that  the  patient  should  daily 
be  exercised  in  walking,  standing,  and  sitting  properly  for  a  specified 
time  under  the  direction  of  some  competent  person.     The  principles  of 


356  ORTHOPEDIC  SURGERY. 

the  "  setting-up  "  drill  of  recruits  in  all  armies  are  applicable,  with  mod- 
ifications, to  patients  of  this  class.  When  resting  during  the  hour  of 
drill  the  patient  should  remain  recumbent.  After  the  drill  is  over,  such 
precaution  should  be  taken  as  will  prevent  the  persistence  for  any 

length  of  time  of  a  faulty  attitude.  This 
should  not  be  done  (out  of  the  drill  time) 
by  constant  correction,  but  by  the  proper 
arrangement  of  the  play  hours  and  a  super- 
vision of  the  chairs  when  reading  and 
studying.  Walking,  running,  and  active 
games  should  be  encouraged,  while  read- 
ing, except  in  proper  position,  should  be 
discouraged.      The    treatment    is    strictly 

Fig.  317.— Seat  Elevated  on  One        pOStural. 

Side  for   Changing  Lumbar  jj^g  ^g^j^l  ^^^  habits  of  position  are  as 

Curves.  . 

follows :  Standing  on  one  leg,  sittmg  at  too 
low  a  table,  sitting  in  a  twisted  position,  and  sleeping  always  on  one 
side  with  too  high  a  pillow  for  the  head. 

Gymnastics.- — In  many  early  cases  the  faulty  attitudes  are  clearly 
the  result  of  muscular  weakness.  The  increase  in  height  has  not  been 
accompanied  by  a  corresponding  development  in  muscle.  This  condi- 
tion is  frequently  met  in  rapidly  growing  children,  and  is  one  of  the 
most  common  causes  of  lateral  curvature.  Here  proper  gymnastics  are 
indicated,  but  they  should  be  prescribed  and  carried  out  with  much 
care.  In  the  more  marked  cases  the  children  are  unable  to  bear  much 
exercise  without  fatigue.  Those  exercises,  therefore,  chiefly  needed  in 
correcting  the  deformity  should  be  the  only  ones  prescribed.  The 
usual  class-work  of  gymnasium  is  to  be  avoided,  as  such  cases  require 
the  individual  attention  of  a  competent  person,  who  will  see  that  no 
faulty  position  is  taken  during  the  exercises. 

Each  case  may  be  regarded  as  far  as  exercises  are  concerned  as  a 
separate  problem  to  be  worked  out  individually. 

Light  Gymnastics. — It  is  not  a  difficult  matter  to  devise  simple 
and  practicable  exercises  to  develop  the  muscles  chiefly  at  fault,  viz., 
the  muscles  of  the  back  and  loins.  The  strength  of  a  patient's  back 
muscles  can  be  determined  in  a  ready  way  by  attaching  a  cord  to  the 
front  of  a  cap  tied  to  the  head,  and  fastening  this  cord  to  a  spring  bal- 
ance. The  patient,  seated  and  strapped  to  a  seat  at  the  proper  distance 
from  the  spring  balance,  held  firmly  by  an  assistant,  is  directed  to  bend 
backward,  keeping  the  back  straight  so  far  as  is  possible.  This  exer- 
cise is  repeated  as  many  times  as  advisable. 

The  patient  stands  with  the  heels,  back,  and  occiput  against  a  pro- 
jecting corner  (of  furniture  or  doorway),  and  places  the  elbows  (the 
arms  being  flexed)  as  far  back  as  possible. 


LATERAL    CURVATURE   OF   THE  SPINE. 


357 


The  patient,  seated  on  a  stool  or  chair,  should  place  the  feet  behind, 
and  on  the  inner  side  of,  the  front  legs  of  the  chair,  and  slowly  bend 
sideways ;  the  assistant,  resisting  on  the  head,  determines  the  strain  on 
the  muscles  of  either  side. 

General  developmental  exercises  for  the  back,  shoulders,  and  abdo- 
men, when  taken  with  the  spine  straight  and  the  carriage  of  the  body 
correct,  constitute  the  best  general  scheme  for  the  treatment  of  such 
cases. 

Cases  will  be  seen  of  such  feeble  muscular  strength  that  it  is  advis- 
able to  begin  with  those  which  demand  the  least  muscular  effort  in 


Fig.  318.— Trunk  Bending  Apparatus,  Raising  the  Weight  and  Localizing  the  Movement. 

(Schulthess.) 


maintaining  a  symmetrical  attitude.     For  these  cases  exercises  with  the 
patient  recumbent  are  desirable,  such  as  the  following : 

1.  The  patient  lies  upon  the  back  with  arms  at  the  side,  the  feet  are 
held,  and  the  patient  raises  the  head  and  chest. 

2.  The  patient  lies  on  the  face  and  raises  the  head  and  chest. 

3.  The  patient  takes  i  and  2  with  the  arms  behind  the  head  and  the 
elbows  squared  back. 

4.  The  patient  lies  on  the  face  with  the  trunk  projecting  over  the 
edge  of  a  table  and  the  hands  on  the  hip,  and  raises  the  trunk  to  a  hori- 
zontal position. 


358  ORTHOPEDIC  SURGERY. 

The  same  exercises,  if  repeated  with  the  arms  extended  above  the 
head,  require  more  muscular  effort. 

If  the  patient  has  gained  sufficient  strength,  a  series  of  Ught  dumb- 
bell exercises  with  bells  weighing  from  one  to  five  pounds  can  be  pre- 
scribed, carried  on  with  the  patient  recumbent,  similar  to  those  just 
mentioned.     Care  should  be  taken  that  they  are  correctly  performed. 

After  this,  follow  light  symmetrical  dumbbell  exercises  with  the 
patient  standing  in  a  correct  position.  The  work  of  the  patient  should 
be  tabulated  and  carefully  graded.  This  is  to  be  followed  by  heavier 
work  of  the  same  general  type. 

Heavy  Gymnastics. — The  method  of  muscular  development  by 
means  of  the  use  of  heavy  weights  has  been  employed  with  advantage 
in  cases  of  scoliosis.  This  was  first  thoroughly  carried  out  by  Tesch- 
ner,  of  New  York,'  and  in  many  cases  has  been  followed  by  excellent 
results. 

The  patient  should  exercise  daily  with  light  dumbbells  weighing 
from  one-half  to  five  pounds,  and  three  times  a  week  exercises  under 
supervision  with  heavier  weights  should  betaken.  The  weight  of  these 
heavy  bars  and  bells  and  the  amount  of  the  exercise  depend  upon  the 
strength,  capacity,  and  endurance  of  the  individual.  Each  patient  is 
put  to  his  limit  of  work  at  each  visit,  and  this  limit  is  extended  at  each 
visit.  This  increase  is  largely  dependent  on  correctness  of  posture  and 
precision  in  the  work. 

Bells  weighing  from  five  pounds  to  twenty  and  thirty  pounds  each 
and  steel  bars  and  bar-bells  w-eighing  twenty-six  pounds  and  upward 
■can  be  used.     The  exercises  are  as  follows: 

Bells  are  pushed  from  the  shoulders  above  the  head  alternately  as 
often  as  the  patient's  strength  permits.  The  patient  swings  a  heavy 
bell  with  one  hand  from  the  floor,  above  the  head  and  down  again,  the 
elbow  and  wrist  being  fixed  and  the  motion  repeated  as  often  as  possi- 
ble in  a  systematic  manner;  then  with  the  other  hand  the  same  number 
•of  times,  and  later  with  both  hands.  This  exerts  all  the  extensor  mus- 
cles from  the  toes  to  the  head  in  rapid  succession. 

When  a  heavy  ball  is  pushed  or  swung  above  the  head  on  the  side 
opposite  the  scoliosis,  the  action  of  the  back  muscles  is  such  as  to  cause 
the  curved  spine  to  approximate  a  straight  line.  A  similar  result  is 
produced  when  a  heavy  weight  is  held  by  the  side  of  the  erect  body  on 
the  scoliotic  side,  the  arm  being  at  full  length. 

When  a  heavy  bar  is  raised  above  the  head  with  both  hands,  the 
patient  must  fix  the  eyes  upon  the  middle  of  the  bar  to  maintain  the 
equilibrium.  This  necessitates  the  bending  of  the  head  backw^ard,  the 
straightening  and  hyperextending  of  the  spine,  and  consequently  cor- 

^  Annals  of  Surgery,  August,  1S95  ;  Orth.  Trans. .vol.  ix. — Erich:  N.  Y.  Med 
Journal,  October  7th,  1899 


LATERAL    CURVATURE   OF   THE  SPLNE. 


359 


recting  a  faulty  position  with  a  weight  superimposed.  The  heavier  the 
weight  put  above  the  head,  whether  with  one  hand  or  with  two,  the 
more  the  patient  must  exert  himself  to  attain  and  maintain  a  correct  or 
an  improved  attitude  in  order  to  sustain  the  equilibrium. 

When  a  patient  lying  supine  upon  the  floor  raises  a  heavy  bar 
above  the  head  so  that  the  arms  arc  perpendicular  to  the  floor,  the 
weight  of  the  bar,  the  position  and  weight  of  the  body,  and  the  action 
of  the  muscles  tend  to  broaden  the  entire  back  and  shoulders,  and  a 


Fig.  319.— Paper  Jacket,  Hinged.      (Weigel.) 

slow  downward  movement  tends  to  widen  the  entire  chest,  and  most 
markedly  the  shoulders.  Pushing  the  bells  above  the  head,  swinging 
them  with  each  hand  and  with  both  hands  together,  raising  a  bar  above 
the  head  standing  and  lying  down,  and  the  exercises  above  enumerated 
constitute  a  day's  work. 

Whether  light  or  heavy  exercises  are  used,  persistence  is  necessary 
for  success.  It  is  needless  to  add  that  the  patient  should  exercise 
under  careful  supervision,  rest  being  prescribed  as  a  part  of  the  daily 
treatment,  the  amount  of  work  being  regulated  each  day. 


360  ORTHOPEDIC  SURGERY. 

Asymmetrical  Gymnastic  Exercises. — Exercises  formulated  with 
the  expectation  of  isolating  certain  weak  muscles  in  the  back  will,  as  a 
rule,  be  found  impracticable,  for  the  reason  that  it  is  difificult  to  deter- 
mine the  weakness  of  any  individual  muscle,  and  because  in  a  lateral 
curve  it  is  difficult  if  not  impossible  to  exercise  a  weak  muscle  on  the 
convexity  of  a  curve  without  the  danger  of  exercising  also  the  strong 
muscle  of  the  compensatory  curve.  As  a  rule,  symmetrical  muscular 
exercises  with  the  body  held  as  symmetrically  as  possible  are  the  most 
practicable  in  lateral  curvature.  A  few  asymmetrical  ones  may  be  used 
if  marked  difference  in  the  strength  of  one  arm  or  leg  is  present,  and 
an  increased  amount  of  work  can  be  given  to  the  weaker  limb  or  side. 

Fixation  Appliances. — It  is  manifest  that  during  the  formative  period 
of  growth  faulty  attitudes  are  to  be  avoided.  Recumbency  being  inap- 
plicable for  a  long  period,  and  gymnastics  being  possible  only  for  a  lim- 
ited portion  of  the  day,  some  form  of  appliance  which  checks  faulty 
positions  is  often  desirable. 

Corsets  made  of  plaster-of-Paris,  leather,  paper,  and  celluloid,  or 
cloth  stiffened  with  steel,  act  as  supports  and  limit  faulty  positions. 
Weakening  of  the  muscles  from  the  use  of  such  appliances  must  be 
combated  by  systematic  gymnastics.  These  appliances  should  be  re- 
movable if  designed  simply  as  means  of  preventing  faulty  attitudes, 
and  are  made  in  the  same  way  as  removable  corsets  for  the  convales- 
cent stage  of  Pott's  disease,  except  that  they  are  modelled  to  correct 
certain  positions  and  not  to  fix  the  spinal  column.  In  general,  support 
of  this  sort  is  indicated  when  the  patient  shows  no  marked  improve- 
ment under  gymnastic  work,  but  drops  back  after  each  exercise  period. 
It  is  evident  that  under  these  conditions  no  satisfactory  progress  will 
be  made  without  support. 

When  side  inclination  of  the  trunk  exists  to  such  an  extent  as  to 
make  the  lumbar  curve  the  chief  curvature,  raising  the  pelvis  (by  plac- 
ing an  increased  thickness  under  the  sole  of  the  shoe  on  the  apparently 
lower  hip,  and  a  pad  under  the  lower  buttock  in  sitting)  will  serve  as 
partial  correction. 

II.  Treatment  of  Structural  Cases. 

Corrective  Measures. — When  shortened  ligaments  and  muscles  are 
situated  so  that  they  serve  as  a  check  to  the  free  movement  of  the 
spine,  purely  muscular  exercises  are  not  sufficient  for  corrective  stretch- 
ing. Gymnastics  alone  are  therefore  inadequate  as  a  system  of  treat- 
ment in  cases  of  this  class,  although  useful  as  an  adjuvant  and  as  a  pre- 
vention of  relapse  after  correction  by  other  means.  It  has  been  proved 
by  clinical  experience  and  by  experiments  on  cadavers  that  pressure 
upon  certain  parts  of  the  thorax — that  is,  on  the  ribs — is  effective  in 
correcting  the  distortion  of  the  spinal  column  in  such  structural  cases. 


LATERAL    CURVATURE   OF   THE  SPLNE.  361 

This  corrective  force  needs  to  be  adequately  and  correctly  applied,  and 
is  analogous  in  its  aim  to  the  repeated  correction  used  by  those  train- 
ing themselves  to  become  contortionists  or  dancers. 

It  is  also  true  that  bending  the  trunk  to  the  side  by  force  moder- 
ately applied  will  often  place  the  spine  in  an  improved  and  corrected 
position.  Such  procedures  as  these  increase  the  flexibility  of  the  spinal 
column  in  the  desired  direction  and  make  improved  attitude  possible. 
It  is  manifest,  however,  that  if  a  corrective  force  is  to  be  beneficial  in 
scoliosis  it  must  be  made  effective  on  the  curved  and  not  on  the  normal 
portion  of  the  spine.  The  spinal  column  above  and  below  the  curved 
part  where  the  corrective  force  is  to  be  applied  must  be  secured ;  oth- 
erwise the  more  flexible  and  normal  part  of  the  spine  will  be  more 
affected  by  the  corrective  force  than  will  the  abnormally  rigid,  curved, 
and  twisted  part.  This  is  true  not  only  of  corrective  force  applied  by 
pressure,  but  of  attempts  to  correct  the  curve  by  posture  and  exercises 
which  have  as  their  aim  the  stretching  of  shortened  ligaments. 

Pressure  to  the  ribs  for  this  purpose  should  be  applied  as  near  their 
attachment  as  possible,  in  order  to  spend  as  much  of  the  force  as  possi- 
ble in  correcting  the  deviation  of  the  spine  and  as  little  as  possible  in 
bending  the  ribs  on  the  spine. 

Corrective  measures  are  either  applied  intermittently  in  the  milder 
cases  or  continuously  in  the  more  resistant  cases. 

Intermittent  Correction  by  Exercises. — These  can  be  given 
with  much  precision  by  means  of  elaborate  appliances  devised  for  the 
purpose,  of  which  those  used  by  Schulthess  are  the  best.  Simpler 
forms  can  be  employed  with  benefit  if  care  is  exercised  in  localizing 
carefully  the  correcting  force.  These  involve  some  mechanical  restraint 
of  a  portion  of  the  patient's  trunk  and  swinging  or  stretching  the  rest 
of  the  trunk  in  a  direction  to  straighten  the  curve.  Great  care  is  nec- 
essary in  these  exercises,  which  are  flexibility  exercises  and  not  prima- 
rily designed  to  strengthen  the  muscles.  There  is  a  danger  of  increas- 
ing the  flexibility  of  the  wrong  portion  of  the  column  and  increasing 
the  compensatory  curves.  A  few  exercises  of  this  type  may  be  men- 
tioned. Any  loss  or  impairment  of  spine  flexibility,  local  or  general, 
should  be  remedied,  as  a  normal  flexibility  in  all  directions  is  an  im- 
portant matter.  Symmetrical  stretching  is  of  use  in  such  cases.  As 
examples  of  this  may  be  mentioned : 

1.  Hanging  by  the  arms  or  suspension  by  the  head  in  a  Say  re  sling. 

2.  The  patient  stands  with  the  head  and  shoulders  in  a  Sayre  sling; 
the  feet  are  fastened  to  the  floor,  and  the  patient  rotates  the  trunk 
through  a  circle,  first  in  one  direction  and  then  in  the  other. 

3.  Sitting  or  standing,  the  patient  rotates  the  trunk  from  right  to 
left,  and  then  from  left  to  right. 

4.  The  patient  hangs  from  a  bar  and  by  a  muscular  effort  rotates  the 


362 


ORTHOPEDIC  SURGERY. 


pelvis  and  legs,  first  in  one  direction  and  then  in  the  other.     This  ex- 
ercise should  be  done  with  some  force. 

If  round  shoulders,  contracted  chest,  or  pronated  feet  coexist  with 
the  lateral  curve,  suitable  exercises  should  be  added. 

As  examples  of  asymmetrical  exercises  to  increase  flexibility,  the  fol- 
lowing may  be  men- 
tioned : 

1.  The  patient  sits 
or  stands  with  the  legs 
apart  and  bends  to  the 
side  of  the  convexity 
of  the  curve,  or,  with 
the  arm  of  the  concave 
side  across  the  top  of 
the  head  and  the  arm 
of  the  convex  side 
around  in  front  of  the 
abdomen,  the  patient 
bends  to  the  convex 
side  through  the  ribs 
and  not  through  the 
waist. 

2.  The  patient  lies 
on  the  face  with  the 
feet  held.  With  the 
hands  behind  the  head 
and  the  elbows  raised, 
the  body  is  raised  and 
swayed  toward  the 
convex  side,  the  pa- 
tient trying  to  "  puck- 
er in "  the  bulging 
ribs  and  not  to  bend 
in  the  lumbar  con- 
cavity. 

3.  The  patient 
stands  with  the  convex 
side    leaning    against 

the  padded  edge  of   a  table  or  a  padded   roll,  and   bends   over  the 
pad  which  presses  against  the  convexity. 

4.  The  patient  stands  with  the  feet  apart  and,  in  a  right  dorsal,  left 
lumbar  curve,  the  right  hand  is  placed  against  the  convexity  on  the 
ribs  with  the  elbow  out  from  the  side,  and  the  left  arm  on  top  of  the 
head  or  on  the  left  side  of  the  pelvis,  according  to  the  position  which 


Fig.  320.  — Apparatus  to  Afford  Resistance  to  the  Left  Shoul- 
der, which  Pushes  to  the  Left  Against  the  Pad  Raising  the 
Weight  on  the  Right  Side  of  the  Apparatus.  The  pelvis  is 
fixed.     (Schulthess.) 


LATERAL    CURVATURE   OE    THE  SPLNE. 


363 


seems  to  give  the  best  correction.     The  right  hand  then  presses  the 
convexity  to  the  left,  using  as  much  force  as  possible. 


Fig.  32i.-Apparatus  for  the  Forcible  Correction  of  Lateral  Curvature  in  Suspen 


(Weigel.) 


spension. 


5.  Remembering  that  a  twist  to  the  right  causes  a  left  lateral  curve, 
beginning  below  above  the  lumbar  region,  a  twist  to  the  right  may  be 


364 


ORTHOPEDIC  SURGERY. 


used  as  an  exercise  for  antagonizing  a  curve  to  the  right  in  that  region. 
The  patient  sits  back  to  the  surgeon,  the  hands  behind  tlie  head  and 
the  elbows  squared  back,  and,  while  the  pelvis  is  held,  twists  the  head 
and  shoulders  as  far  to  the  right  as  possible. 

The  variations  to  be  made  in  these  exercises  are  many,  but  compli- 
cated exercises  are  undesirable,  as  it  is  not  possible  to  analyze  their 
anatomical  effect,  and  the  risk  necessarily  involved  in  asymmetrical 
work  of  inducing  or  increasing  compensatory  curves  is  increased. 

Such  exercises  should  be  given  with  great  care,   with  the  back 

exposed  to  view  as  a  rule,  and  should 
be  followed  by  a  period  of  rest.  In 
order  to  make  such  exercises  effective 
in  the  spine  the  pelvis  should  in  all 
cases  be  fixed  during  the  exercises. 

The  rules  for  the  simultaneous 
use  of  supporting  appliances  are  the 
same  as  those  given  in  speaking  of 
flexible  curves. 

Intermittent  Stretching  by 
Appliances. — Intermittent  correc- 
ti\'e  force  may  be  applied  passively 
for  stretching  at  frequent  periods 
by  means  of  appliances  to  be  men- 
tioned in  speaking  of  the  use  of  cor- 
rective jackets.  This  procedure  is 
advisable  when  free  standing  or 
other  exercises  need  to  be  reinforced 
temporaril}"  by  more  accurately  local- 
ized stretching.  The  same  procedure 
is  advisable  in  many  cases  as  a  pre- 
liminary to  the  application  of  cor- 
rective jackets,  in  order  to  obtain 
beforehand  greater  flexibility  in  the 
direction  of  correction. 
Corrective  Measures — Continuous  Use  of  Force. — In  certain  cases 
the  curves  are  too  resistant  to  be  altered  materially  by  intermittent  cor- 
rection. In  suitable  cases  attempts  can  be  made  to  correct  the  curves 
by  a  method  of  constant  pressure,  as  it  has  been  demonstrated  that  the 
shape  of  bone  is  altered  by  constant  pressure.  This  is  shown  not  only 
in  dentistry  in  the  success  in  altering  the  shape  of  the  jaw,  in  the  cor- 
rection of  congenital  club-foot  with  congenital  bone  changes,  but  also 
pathologicallv  in  the  artificial  development  of  structural  changes  in 
bone  seen  in  the  Chinese  lady's  foot,'  Wullstein's  experiments  in  the 
'  P.  Brown:  Journal  Med.  Research,  December,  1903. 


Fig.  ^22. — Corrective  Plaster  Jacket  with 
Head-piece  Applied  for  the  Correction 
of  Scoliosis.     (Wullstein.) 


LATERAL   CURVATURE   OF   THE  SPINE. 


36; 


artificial  development  of  lateral  curvature  already  mentioned,  in  the  pro- 
duction of  lateral  curvature  in  different  occupations/  and  in  the  altera- 
tion of  the  jaw  from  scar  contraction  after  burns  and  the  alteration  of 
the  shape  of  the  face  in  torticollis.  For  the  application  of  this  method, 
plaster  jackets  should  be  applied  to  the  patient  in  a  corrected  or  over- 
corrected  position. 

It  is  evident  that  this  method  of  correction  is  chiefly  applicable  dur- 
ing the  growing  period. 

Corrective  plaster  jackets  can  be  applied,  as  for  caries  of  the  spine, 
with  the  patient  in  a  standing  or  sitting  position  or  recumbent,  either 
lying  on  the  face  or  back.  Jackets  are  applied  as  for  caries  of  the 
spine,  but  much  more  skill  is  required,  as  the  amount  of  correcting  force 
and  method  of  applying  require  the  exercise  of  judgment.     If  a  good 


Fig.  323.  — Diagram  of  Plaster  Jacket. 


Fig.  324. — Slipping  of  Plaster  Jacket. 


deal  of  force  is  employed,  the  patient  may  be  exposed  to  subsequent 
discomfort.  It  is  usually  preferable  to  use  correcting  force  without  an 
anaesthetic  and  apply  jackets  at  short  intervals. 

Suspension  or  a  traction  force  is  manifestly  of  less  value  than  in 
caries  of  the  spine,  as  the  affected  portion  of  the  spine  in  lateral  curva- 
ture is  always  the  most  resistant  portion,  while  in  caries  the  curve,  if 
in  a  stage  suitable  for  treatment,  is  less  resistant.  The  most  economi- 
cal application  of  force  in  straightening  a  stiffly  curved  stick  is  by 
bending  it  over  a  resistant  pressure  rather  than  b}'  pulling  each  end. 
Experiments  on  cadavers  show  that  this  is  applicable  to  the  human 
trunk." 

If  the  patient  is  seated  or  standing,  a  head  sling  will  be  of  assistance, 
with  some  suspension  force  to  steady  the  upper  part  of  the  trunk. 
Traction  force  may  be  used  in  the  recumbent  position,  though  it  is 
rarely  needed. 

'  Lane:  Guy's  Hospital  Reports,  xxviii. 

-  Lovett:  American  journal  of  Anatomy.  1904. 


366  ORTHOPEDIC  SURGERY. 

The  relative  advantages  of  the  different  positions  of  the  patient  in 
the  appHcation  of  a  corrective  jacket  are  as  follows : 

With  the  patient  standing  or  seated  it  is  much  easier  to  apply  the 
bandage  on  all  sides  of  the  patient  than  when  the  patient  is  recumbent, 
and  for  this  reason  is  preferable  in  applying  jackets  to  the  neck  and 
shoulders.  In  the  upright  position  the  position  of  the  head  relative  to 
the  thorax  is  that  usual  in  locomotion,  while  in  recumbency  an  altera- 
tion in  the  normal  thorax  takes  place.  Recumbently  applied  jackets 
are  therefore  less  comfortable  to  the  patients  than  those  applied  with 
the  patient  upright. 

If  the  patient  is  seated  it  is  easier  to  correct  lordosis  or  any  torsion 
of  the  pelvis  than  if  the  patient  is  standing,  but  in  the  seated  position 


Fig.  325. — Apparatus  (Kyphotone)  for  the  Application  of  Forcible  Jackets  in  Scoliosis 
during  Recumbenc)'  on  the  Back.     (R.  T.  Taylor.) 

the  surgeon  needs  to  take  especial  pains  in  arranging  the  seat  so  as  to 
enable  him  to  apply  a  jacket  which  will  hold  the  pelvis  firmly. 

Much  greater  correcting  pressure  can  be  applied  with  the  patient  in  a 
recumbent  position,  as  the  superimposed  weight  is  not  an  influence  to  be 
opposed.  In  recumbency  on  the  face  lordosis  can  be  overcome  more 
readily  than  if  the  patient  lies  upon  the  back.  It  is  less  easy,  however, 
to  secure  a  desirable  expansion  of  the  chest  and  arching  backward  of 
the  spine  in  the  dorsal  region  in  face  than  in  back  recumbency.  Where 
there  is  much  rotation  to  be  corrected,  the  recumbent  position  is  to  be 
preferred.  Where  side  deviation  is  the  more  important  feature,  the 
upright  position  is  to  be  considered  also. 

The  simplest  method  of  application  of  a  corrective  jacket  is  for  the 
patient  to  sit  or  stand  in  the  centre  of  a  four-upright  frame.  The 
head  is  secured  in  a  head  sling  with  moderate  traction.  Webbing 
straps  pass  from  the  different  uprights  and  can  be  made  to  exert  press- 
ure in  different  directions  as  desired.  These  are  included  in  the  jacket, 
the  emerging  portions  being  cut  off.  A  more  complicated  appliance, 
with  more  precision  in  the  application  of  the  force,  is  one  furnished 


LATERAL    CURVATURE   OF    THE  SPINE. 


367 


with  circular  steel  bands  connected  with  the  uprights.  From  these 
adjustable  bands  screw  pressure  rods  can  be  made  to  exert  pressure  on 
all  desired  parts  of  the  trunk. 

In  the  recumbent  position  the  patient  may  be  placed  with  the  back 
supported  on  a  frame  with  uprights  similar  to  that  used  in  the  applica- 
tion of  corrective  jackets  in  Pott's  disease,  except  that  the  pressure 
points  are  applied  in  the  back,  not  upon  the  transverse  processes,  but 
upon  the  backward  prominence  of  the  ribs.  Correction  of  lateral  devi- 
ation can  be  furnished  by  horizontal  traction,  if  necessary,  or  by  side 
pressure.     Felt  padding  is  needed  over  the  portions  of  the  body  which 


Fig.  326.— Apparatus  for  the  Application  of  Plaster  Jackets  during  Recumbency  on  the  Face, 


are  but  little  protected  by  fatty  tissue ;  the  plaster  bandages  should  be 
applied  high  up  under  the  drooping  shoulder  and  over  the  shoulder 
from  behind,  across  the  neck.  When  the  plaster  is  sufficiently  hard- 
ened the  patient  can  be  lifted,  the  detachable  plates  which  are  thor- 
oughly padded  remaining  in  the  jacket. 

A  simple  method  of  application  of  a  corrective  jacket  in  an  inclined 
or  recumbent  position  is  to  secure  the  patient  firmly  in  the  centre  of 
the  four-upright  frame  used  for  applying  a  jacket  in  the  upright  posi- 
tion and  inclining  the  whole  frame  backward.  The  correcting  straps. 
will  need  readjustment  for  proper  correcting  force  when  the  patient 
is  changed  from  the  upright  to  the  recumbent  position. 

An  effective  appliance  for  corrective  jackets  in  face  recumbency  is 
in  use  at  the  Boston  Children's  Hospital,  devised  by  Dr.  Z.  B.  Adams. 
The  apparatus  consists  of  a  heavy  gas-pipe  frame,  three  by  four  feet. 
The  patient  lies  face  downward  on  two  webbing  strips,  running  from 
end  to  end  of  the  frame,  with  the  legs  flexed.  Near  the  bottom  of  the 
frame  is  an  adjustable  crossbar  bent  to  fit  into  the  flexure  between  the 


;68 


ORTHOPEDIC  SURGERY. 


thighs  and  the  pelvis,  on  which  the  patient  rests  the  lower  part  of  the 
body.  Sliding  on  this  bar  are  two  arms,  which  slide  in  and  clamp  down 
on  the  buttocks,  holding  the  pelvis  steady  on  the  crossbar.     This  bar 


is  movable  from  side  to  side  in  order  to  induce  or  correct  curvature  in 
the  lumbar  region  when  necessary.  There  are  three  vertical  transverse 
rings,  two  feet  in  diameter,  fastened  to  pieces  on  the  sides  of  the  frame 


LATERAL    CURVATURE   OE   THE  SPLNE. 


369 


so  that  they  can  be  moved  to  any  desired  point  along  the  frame.  These 
rings  are  also  movable  from  side  to  side,  and  by  an  independent  move- 
ment they  can  also  be  rotated  through  a  half  circle.  Any  one  of  these 
movements  can  be  checked  at  any  point  by  turning  a  screw.  The 
shoulders  are  held  by  a  pair  of  axillary  straps  fastened  together  by  a 


strap  across  the  chest  in  front.  These  straps  are  suspended  from  the 
ring  nearest  to  the  top  of  the  frame  and  can  be  made  to  hold  the  shoul- 
ders in  any  desired  degree  of  twist  by  a  rotation  of  the  ring. 

Each  ring  is  provided  with  two  long  screws  at  the  two  poles  of  the 
ring.     These  screws  are  adjustable  upon  the  ring  and  can  be  set  at  an)- 
desired  angle  to  it.     By  rotating  the  ring  and  adjusting  the  angle  of  the 
24 


370 


ORTHOPEDIC  SURGERY. 


screws  they  can  be  made  to  screw  down  or  up  upon  any  part  of  the 
back  or  chest. 

For  the  apphcation  of  the  jacket  the  patient  hes  on  the  face  on  the 
two  webbing  strips,  the  lower  part  of  the  trunk  resting  on  the  cross  rod 
and  the  bars  clamping  the  buttocks;  the  feet  rest  on  the  floor  and  the 
arms  are  extended  above  the  head.  The  rings  are  then  adjusted  at  the 
two  levels  where  it  is  desired  to  make  correction,  generally  in  the  dorso- 
lumbar  and  the  dorsal  regions.  For  side  correction  a  webbing  strap  is 
fastened  to  one  side  of  the  ring,  carried  around  the  patient's  side  over 


Fig. 


-Lateral  Curvature  Before 
Correction. 


Fig.  330. — Lateral  Curvature  Three 
Weeks  After  Correction. 


a  heavy  pad  of  felt  and  back  to  the  ring.  The  same  is  done  to  the 
other  ring  at  the  other  level  where  side  correction  is  desired,  while  the 
top  ring  controls  the  shoulders.  The  rings  are  then  pulled  to  one  side, 
the  bandages  around  the  patient  tighten,  and  any  endurable  degree  of 
side  correction  is  obtained. 

When  the  side  correction  is  made  the  screws  are  then  screwed  down 
on  to  the  patient,  their  points  being  protected  by  sheet-iron  pads,  two 
by  three  inches,  which  are  covered  with  heavy  felt.  These  pads  are 
incorporated  in  the  jacket. 

The  shoulders  are  controlled  by  the  axillary  pads  attached  to  the 
upper  ring  along  with  screw  pressure  up  or  down  as  desired.  In  the 
correction  each  level  is  separately  attacked  from  below  upward. 


LATERAL    CURVATURE   OF   THE  SPLNE.  371 

A  plaster  jacket  is  applied  to  the  patient  held  in  this  way  with  a 
great  amount  of  force  at  the  operator's  disposal. 

In  applying  corrective  jackets  it  is  to  be  remembered  that  there  are 
two  elements  of  the  deformity  demanding  correction — one,  the  lateral 
curve,  to  be  corrected  by  side  force;  the  other,  the  rotation,  to  be  cor- 
rected by  a  twisting  force.     Any  use  of  force,  to  be  effective,  must  be 


Fig.  331.— Case  of  Scoliosis  before  Operation  Showing  Lateral  Deviation  of  Spine. 

(Michael  Hoke.) 

met  by  counter-points  of  resistance  or  the  whole  spine  will  be  pushed 
to  one  side  or  twisted  as  a  whole. 

High  dorsal  curves  are  not  likely  to  be  much  improved  by  correc- 
tive jackets,  because  no  satisfactory  point  of  counter-pressure  can  be 
found  above  the  curve.  Lumbar  curves  are  also  generally  better 
treated  by  other  means,  because  there  are  no  ribs  to  exert  side  pressure 
on  this  region  and  direct  side  force  cannot  be  exerted. 


372  ORTHOPEDIC  SURGERY. 

Corrective  plaster  jackets  should  embrace  the  shoulders  and,  in 
cases  of  high  dorsal  curves,  the  neck,  and  should  not  be  removable. 
Windows  can  be  cut  in  the  jacket  over  the  portion  of  the  trunk  where 
pressure  is  undesirable.  At  first  the  patient  will  need  supervision, 
but  later  can  go  about  freely.  Jackets  should  be  repeated  at  short 
intervals,  preferably  two  or  three  weeks,  and  applied  as  long  as  cor- 


Pig.  332. — Case  of  Scoliosis  Before  Operation  Showing  Rotation.     (Michael  Hoke.) 

rection  can  be  obtained.  This  stage  of  treatment  is  followed  by  that  of 
removable  jackets  and  gymnastic  exercise. 

The  amount  of  correcting  force  used  is  a  matter  of  judgment,  as  is 
also  the  time  when  corrective  pressure  treatment  should  be  discontin- 
ued. Supporting  jackets  are  necessary  for  many  months  after  correc- 
tion has  stopped,  and  should  be  discontinued  gradually. 

Adult  Cases. — When  the  bones  have  become  hardened  by  growth, 
marked  correction  is  not  possible  either  by  intermittent  or  by  constant 
pressure.  The  treatment  must  be  palliative  and  consist  of  gymnastics, 
massage  or  electricity  to  relieve  symptoms,  accompanied  or  not,  ac- 


LATERAL    CURVATURE   OF   THE  SPINE. 


373 


cording  to  circumstances,  by  corsets  as  a  partial  support  to  superim- 
posed weight. 

Treatment  bv  Operation. 

Operative  attempts  consisting  of  resection  of  the  projecting  ribs, 
performed  by  Volkmann  in  1889  and  Hoffa '  in  a  few  instances,  have 
been  made  in  cases  in  which  the  distortion  of  the  ribs  resulting  from 


Fig.  333. — Case  of  Scoliosis  After  Operation,     (ilichael  Hoke.) 

rotation  is  so  severe  as  to  preclude  the  possibility  of  correction  by 
other  means.     The  success  obtained  was  not  great. 

Hoke "  has  utilized  this  method,  carefully  executed,  as  a  preliminary 
to  later  jacket  correction,  on  the  theory  that  in  some  cases  with  marked 
distortion  of  the  thorax  the  ribs  constitute  an  impediment  to  correction 
of  the  rotation.  The  success  obtained  by  Hoke  was  satisfactory  in  the 
case  in  which  the  treatment  was  reported. 

^  Zeitsch.  f.  orth.  Chir. ,  1S96,  401. 

^  Amer.  Jour,  of  Orthop.  Surgery,  vo!.  i..  No.  2. 


374  ORTHOPEDIC  SURGERY. 

Braces  mid  Corsets. — Treatment  by  the  use  of  spinal  braces  and 

spinal  corsets  alone,  other  than  the  temporary  use  of  plaster  jackets 

applied  under  corrective  pressure,  is  not  advisable.  These  serve  only 
as  an  adjuvant  to  other  treatment. 

Summary  of  Treatment. 

If  the  back  is  flexible  and  no  observable  osseous  change  has  taken 
place  and  the  curvature  disappears  during  suspension  or  recumbency, 
the  treatment  should  be  postural  and  gymnastic.  The  gymnastics 
should  as  a  rule  be  "light,"  symmetrica]  work.  Asymmetrical  exer- 
cises may  form  a  subordinate  part  of  the  treatment.  Corsets  are 
needed  in  the  more  marked  cases  where  exercises  alone  do  not  effect 
improvement. 

When  the  curve  is  somewhat  fixed  but  fair  flexibility  remains,  the 
treatment  should  consist  of  corrective  stretching  by  gymnastics  or 
appliances  and  heavy  and  light  symmetrical  gymnastics.  Supports  will 
be  required  under  the  same  conditions  as  those  mentioned  for  flexible 
cases. 

In  structural  cases  with  rigid  curves,  gymnastics  are  of  use  only  as 
an  adjuvant,  and  corrective  force  intermittently  exerted  by  appliances 
and  gymnastics  or  continuously  exerted  by  means  of  corrective  jackets 
are  the  modes  of  treatment  to  be  considered.  The  latter  is  the  proper 
method  for  the  severer  cases.  Severe  structural  cases  have  been  oper- 
ated upon  with  fair  success.  Severe  structural  cases  in  adults  are  best 
treated  by  support,  massage,  and  exercises  to  secure  a  better  general 
carriage. 

The  length  of  time  needed  for  treatment  varies  necessarily.  In 
general  it  may  be  stated  that  growing  children  wdth  a  tendency  to 
faulty  attitude  need  careful  inspection  during  the  years  of  growth. 
The  inspection  need  not  be  frequent,  and  will  vary  from  three  months 
to  six  months  according  to  the  rate  of  growth.  In  light  cases  a  few 
weeks'  supervision  of  gymnastics,  followed  by  monthly  or  quarterly  in- 
spection, is  all  that  is  necessary.  In  severer  cases  the  treatment  will 
require  at  first  frequent  attendance  and  later,  observation  for  a  period 
of  months  followed  by  inspection  at  longer  intervals. 


CHAPTER   XII. 

OTHER    DEFORMITIES    OF    THE    SPINE    AND 
THORAX. 

Kyphosis  (Round  shoulders. — Causes.— Symptoms. — Prognosis.— Treatment). — 
Lordosis. —  Spondylolisthesis  (Pathology.  —  Etiology.  —  Symptoms.  —  Treat- 
ment).— Deformities  of  the  Thorax  (Pigeon  Breast. — Funnel  Chest. — Con- 
genital Deformities).— Congenital  Elevation  of  the  Scapula. 

At  birth  the  spinal  column  is  straight  and  does  not  present  the 
physiological  curves  constant  in  later  life. 

Physiological  curves  begin  as  soon  as  the  child  attempts  to  sit  and 
stand.  The  cervical  curve  differs  from  the  others  in  that  it  can  be 
obliterated  by  a  change  in  the  position  of  the  head,  while  the  other 
curves  are,  after  early  childhood,  in  part  at  least,  permanent. 

These  curves  var}'  according  to  the  habits,  occupation,  muscular 
system,  sex,  and  figure  of  the  individual.  The  normal  curves  are  for- 
ward in  the  cervical  region,  backward  in  the  dorsal,  and  forward  in  the 
lumbar. 

The  limits  of  movement  in  the  spine  are  set  by  the  shape  of  the 
vertebrae,  the  length  of  the  ligaments,  and  the  tonicity  of  the  muscles. 

Muscles  weakened  by  disease,  by  overuse,  by  too  rapid  growth,  or 
from  any  cause,  which  are  unable  thoroughly  to  do  the  work  expected 
of  them,  do  not  prevent  an  increase  of  these  curves.  The  spine  is 
longer  in  recumbency  than  in  the  erect  position,'  and  the  amount  of 
this  change  will  be  seen  by  referring  to  the  accompanying  table  of 
measurements  of  the  height  of  eleven  people  standing,  and  their  length 
when  lying  upon  the  floor  on  their  backs ;  ten  of  these  were  adults  and 
one  was  a  child.     The  difference  was  relatively  greatest  in  the  child. 


Number. 


I 

3- 
4- 
5- 
6. 

7- 
8. 

9- 

10 

1 1 . 


Age. 


40 
38 
15 

29 
30 

22 

31 
35 


Heiglit  in  Erect 
Position. 


5  ft. 

6  " 

5  " 

5  ;■ 
5 

5  [; 
5 

5  " 

6  " 

5  " 

3  '■ 


8i 

_3_ 

1  1; 

8 

m 


Length  in  Dorsal 
Recumbency. 


5  ft. 

6  " 

5  " 

5  " 

5  " 

5  " 

6  " 

5  " 

6  " 


8^ 
9 


5X3 


Difference. 


4 
TIT 


'  T.  A.  Storey:  Am.  Phys.  Education  Review.  1904. 
:7  5 


376 


ORTHOPEDIC  SURGERY. 


The  term  kyphosis  is  used  to  designate  an  increase  in  the  backward 
dorsal  physiological  curve,  and  the  term  lordosis  to  describe  an  increase 
in  the  forward  physiological  curve  in  the  lumbar  region. 


KYPHOSIS. 


An  increase  of  the  backward  curvature  of  the  spine,  being  an  exag- 
geration of  the  dorsal  curve,  is  most  noticeable  in  the  upper  part  of  the 
spine,  although  it  may  practically  involve  the  whole  column.     It  occurs 


Fig.  334.— Round  Shoulders.  Curve  of 
dorsal  and  lumbar  regions.  Marked 
forward  displacement  of  shoulder. 


Fig.  335. — Round    Shoulders.      Kyphosis 
involves  whole  spine.    (Round  back.) 


(i)  as  a  static  deformity,  which  is  the  commonest  form  seen,  and  is 
known  as  "round  shoulders";  or  {2)  as  the  result  of  an  abnormal  con- 
dition of  the  bones  or  as  a  result  of  paralysis. 


OTHER  DEFORMITIES  OF  SPINE  AND  THORAX.      177 

I.  Round  Shoulders. 

The  term  round  shoulders  is  generally  applied  to  the  stooping  atti- 
tude which  results  from  the  muscular  relaxation  due  to  rapid  growth, 
to  the  assumption  of  improper  attitudes,  and  to  poor  general  condition. 


Fig.  336. — Round  Shoulders  with  Forward  Dis- 
placement of  Scapulas.     Back   comparatively 

flat.  • 


Fig.  337. — Round  Shoulders  with 
Increased  Lumbar  Lordosis. 


It  is  generally  seen  in  children  and  is  likely  to  be  observed  at  any  time 
after  the  age  of  five  or  thereabouts. 

Causes. — The  affection  is  to  be  regarded  as  a  static  one  connected 
with  improper  muscular  support.     The  common  causes  are  as  follows: 

Improper  position  at  school  and  at  home.  The  stooping  position 
necessitated  by  improperly  fitted  school  furniture  used,  by  the  attitude 
assumed  in  writing,  and  the  curled-up  position  assumed  by  children  in 
reading  at  home  are  important  factors  in  the  causation  of  round  shoulders, 
and  what  has  been  said  in  regard  to  the  causation  of  school  scoliosis 
applies  equally  well  to  round  shoulders. 

Rapid  growth,   long  hours  at  school,    insufficient    food,    improper 


378 


ORTHOPEDIC  SURGER\r 


arrangement  of  clothing,  and  too  long  an  active  day  are  causes  inducing 
muscular  debility  and  therefore  favoring  round  shoulders. 

Symptoms. — The  attitude  of  round  shoulders  is  well  known  and  the 
name  itself  is  descriptive.  The  head  is  not  carried  erect,  but  is  run 
forward  somewhat,  the  shoulders  slope  forward,  the  scapulae  are  unduly 


Fig.  338.— Sitting  Position  in  Marked  Round  Shoulders.     The  spine  is  flexible  and  can  be 
straightened  by  muscular  effort. 

prominent  behind  and  may  be  noticed  through  the  clothing  in  severe 
cases,  and  the  whole  shoulder-joint  seems  to  be  forward  of  its  normal 
position,  the  chest  is  narrow  and  flattened,  and  the  expansion  deficient. 
The  lumbar  spine  may  present  an  increased  forward  curvature,  so  that 
the  patient  stands  with  an  abnormally  hollow  back,  or  the  lumbar  spine 
may  be  involved  in  the  backward  curve  and  the  lumbar  curve  dimin- 
ished or  lost.  The  patient's  trunk  is  carried  back  and  the  abdomen 
thrust  forward.  The  pelvis  is  forward  of  its  normal  position.  Some 
degree  of  flat-foot  is  likely  to  coexist,  and  beginning  lateral  curvature 
accompanies  many  of  the  cases. 

\\lth  the  persistence  of  the  attitude  of  round  shoulders  the  muscles 
and  ligaments  in  front  of  the  shoulders  become  shortened  and  those  at 
the  back  stretched.     The  muscular  development  is  generally  poor.     If 


OTHER  DEFORMITIES  OF  SPINE  AND  THORAX.     379 

the  arms  are  carried  to  a  vertical  position  above  the  head,  it  is  done  by 
arching  the  spine  forward  in  the  lumbar  region,  which  is  made  neces- 
sary by  the  contraction  of  the  muscles  connecting  the  arms  and  upper 
chest,  such  as  the  pectoral  muscles.  Pain  is  not  often  complained  of, 
but  ma)'  be  present  in  nervous  children,  especially  girls. 

The  attitude  maybe  partially  corrected  temporarily  by  the  voluntary 
muscular  effort  of  the  patient,  but  the  faulty  attitude  will  be  again 
assumed  almost  immediately,  as  the  muscles  are  unable  to  maintain  the 
corrected  position. 

The  types  of  variation  in  the  physiological  curves  of  the  spine  are 
described^  under  four  heads:  i.  Flat  back.  2.  Flat  hollow  back.  3. 
Round  back.  4.  Round  hollow  back.  The  first  two  are  rather  indi- 
vidual variations  from  the  normal  of  no  especial  significance,  and  will 
be  understood  from  the  figures.  The  last  two  are  the  two  variations 
roughly  grouped  as  round  shoulders. 

Prognosis. — The  prognosis  without  treatment  is  not  good,  so  far  as 
recovery  from  the  deformity  is  concerned,  and  it  may  be  carried  over 
into  adult  life  practically  unchanged.  With  proper  treatment  recovery 
is  to  be  expected. 

Treatment. — In  the  treatment  of  round  shoulders  the  patient  should, 
of  course,  be  put  in  the  most  favorable  surroundings  possible.     Incorrect 


Fig.  339. 

Round  Back. 


Fig.  340. 
Round  Hollow  Back. 


Fig.  341. 
Flat  Hollow  Back. 


(Modified  from  Stafifel  to  show  onh-  upper  part  of  figure.) 

attitudes  at  school  and  at  home  should  be  corrected  so  far  as  possible. 
Errors  in  vision  are  to  be  investigated  and  remedied  if  they  exist.  Undue 
fatigue  and  a  very  long  active  day  are  to  be  avoided. 


'  Staffell:  "Die  mensch.  Haltungstypen."  etc..  Wiesbaden.  1SS9.— See  Lovett: 
"Round  Shoulders."  etc.  (with  literature  1.  Boston  Med.  and  Surg.  Journ., 
November  6th.  1902. 


38o  ORTHOPEDIC  SURGERY. 

Arrangement  of  Clothing. — It  is  a  common  custom  to  fasten 
a  child's  clothes,  including  the  garters,  to  a  waist  which  is  kept  from 
slipping  down  by  two  straps  over  the  shoulders.  These  straps  do  not 
pass  over  the  root  of  the  neck,  but  most  often  over  the  tips  of  the 
shoulders,  where  they  obtain  increased  leverage  to  pull  the  shoulders 


Fig.  343.  — Deformity  of  Shoulders  due  to  the  Pressure  of  Cervical  Ribs.      (Dr.  C.  F.  Painter.) 

downward  and  forward.  The  constant  drag  of  this  not  inconsiderable 
weight  upon  structures  little  suited  to  support  it  is  a  most  important 
factor.  The  arrangement  of  clothing  should  be  improved  and  round 
garters  should  be  worn,  and  the  stockings  should  not  be  fastened  to 
the  waist.  The  trousers  and  skirts  should,  if  possible,  be  supported 
by  a  belt,  and  the  waist  to  which  the  clothes  are  ordinarily  fastened 
should  be  relieved  of  as  much  weight  as  possible.  The  shoulder 
pieces  of  the  waist  should  consist  of  two  straps  passing  close  to  the 
root  of  the  neck  and  not  running  over  the  tips  of  the  shoulders.  In 
this  way  the  constant  drag  of  the  clothing  upon  the  tips  of  the 
shoulders  will  be  avoided.  In  the  more  marked  cases  it  is  some- 
times advisable  to  use  a  support  of  firm  webbing,  one  inch  wide,  which 
runs  transversely  across  the  back  at  the  level  of  the  axillary  line,  passes 


OTHER  DEFORMITIES  OF  SPINE  AND   THORAX,      381 

through  the  axilla  on  each  side,  and  over  the  front  of  the  shoulders, 
crossing  diagonally  in  the  middle  of  the  back.  These  straps  should  be 
sewed  where  they  cross  in  the  back.  To  the  bottom  of  these  straps 
may  be  fastened  the  clothes,  if  necessary,  and  their  weight  will  serve 
in  a  measure  as  a  somewhat  corrective  backward  pull.' 

Gymnastics. — The  gymnastic  treatment  of  round  shoulders  con- 
sists in  stretching  the  contracted  tissues  and  in  drilling  the  child  in  the 
maintenance  of  a  correct  position.  The  stretching  can  usually  be 
accomplished  by  simple  measures.  Suitable  exercises  for  this  purpose 
are  as  follows : 

1.  The  patient  hangs  from  a  bar  by  the  arms. 

2.  The  patient  lies  on  the  back  with  a  hard  roll  under  the  scapulae, 
while  the  arms  are  extended  and  stretched  by  an  assistant  pulling 
them  above  the  head  upward  and  backward. 

3.  The  patient  sits  on  a  stool  with  the  hands  behind  the  head  and 
the  elbows  squared,  and  the  elbows  are  pulled  backward  while  the  knee 


Fig.  344.— Sohulthess'  Apparatus  for  Correctiun  of  Round  Shoulders.     (Schulthess.) 


of  the  manipulator  presses  forward  against  the  spine  on  a  level  with  the 
shoulders. 

The  restoration  of  flexibility  before  giving  corrective  work  is  essen- 
tial. The  use  of  a  greater  degree  of  force  is  sometimes  necessary  to 
accomplish  the  desired  stretching.     This  may  be  accomplished   by  the 

'J.  E.  Goldthwaite  :  Amer.  Jour,  of  Orth.  Surg.,  vol.  i.,  No.  i,  p.  65. 


382 


ORTHOPEDIC  SURGERY. 


application  of  plaster  jackets '  covering  the  shoulders  and  pulling  the 
shoulders  back  with  any  desired  degree  of  force,  or  by  any  form  of 
stretching  apparatus  which  pushes  the  dorsal  region  forward  while 
holding  the  shoulders  back.  As  soon  as  flexibility  is  restored,  postural 
light  gymnastic  work  directed  to  the  muscles  which  it  is  desired  to  de- 


FlG.  345.— Apparatus  for  ytrelchiug  uf  Round  Shoulders. 


velop  should  follow.  The  demands  of  the  cases  are  not  essentially  dif- 
ferent from  those  of  early  scoliosis  so  far  as  the  gymnastic  treatment 
goes,  the  object  in  each  case  being  to  cultivate  a  correct  attitude. 

Apparatus  (Chapter  XXI.,  23). — In  cases  of  marked  round  shoul- 
ders, when  the  children  are  unable  to  maintain  for  any  length  of  time 
a  corrected  position,  some  mechanical  assistance  to  the  extensor  mus- 
cles is  needed.  A  useful  brace  consists  of  a  posterior  horizontal  pelvic 
band,  grasping  the  pelvis  at  the  level  of  the  anterior  superior  spines. 
From  this  run  up,  at  a  distance  of  one  inch  or  less  from  the  spinous 
processes,  two  tempered  steel  uprights,  which  are  turned  out  on  the 
flat  at  their  upper  ends  and  terminate  just  below  the  root  of  the  neck 
well  toward  the  axillary  line,  where  they  are  furnished  with  an  axillary 
straps,  which  run  through  the  arm-pit  and  fasten  to  a  transverse  cross- 
bar on  the  brace.     This  brace  is  furnished  with  an  abdominal  band, 

'  Amer.  Tour,  of  Orth.  Surg  .  vol.  ii..  No.  3. 


OTHER  DEFORMITIES  OF  SPINE  AND   THORAX.      383 

which  runs  from  the  upright  around  the  abdomen,  to  assist  in  the  main- 
tenance of  the  correct  position. 

A  modification  of  this  brace  has  been  made  by  Thorndike  C Chap- 
ter XXL,  33),  by  adding  movable  shoulder-pieces,  so  that  the  patient 
has  a  freer  use  of  the  arms. 


Static  Kyphosis  from  Occupation. 

This  type  of  deformity  occurs  in  adults  and  in  children.  In  adults 
it  is  either  the  result  of  a  condition  acc^uired  in  childhood  carried  over 
into  adult  life,  or  it  is  acquired  by  some  habitual  position  connected 
with  the  occupation  of  the  individual.  It  is  also  seen  in  workmen  who 
carry  heavy  loads  upon  their  shoulders.  The  investigations  of  W.  A. 
Lane '  would  seem  to  indicate  that  the  form  of  deformity  caused  by 
occupation  is  due,  not  only  to  a  change  in  muscles  and  ligaments,  but 
to  a  real  alteration  in  the  shape  of  the  bones.     In  the  same  way,  as  has 


Fig.  346. —Patient  with  Round  Shoulders 
Before  Stretching. 


Fig.  347.— Patient  One  Month  Later  After 
Treatment  by  Stretching. 


been  seen  in  scoliosis,  the  persistence  of  an  exaggerated  curve  of  the 
dorsal  spine  in  a  growing  child  would  be  likely  to  lead  to  a  structural 
change  in  the  bones,  resulting  in  a  permanence  of  the  condition. 
Round  shoulders  from  occupation  are  noticed  in  tailors  who  sit  cross- 
legged  with  the  spine  bent,  cobblers  who  bend  over  their  work,  clerks 

'Practitioner.  May.  1901. 


384  ORTHOPEDIC  SURGERY. 

who  sit  continually  bent  over  a  desk,  and  in  men  performing  heavy 
work,  such  as  blacksmiths,  who  work  continually  bending  over  a  bench 
or  an  anvil.  The  exaggerated  curve  of  the  dorsal  spine  acquired  by 
children  who  bend  over  their  desks  at  school  is  also  to  be  classed  in  a 
measure  as  an  occupation  curvature. 

Kyphosis  may  also  occur  in  (2)  Pott's  disease,  (3)  spondylitis  defor- 
mans, (4)  scoliosis,  (5)  osteomalacia,  (6)  rickets,  (7)  ostitis  deformans, 
(8)  paralysis  of  the  back  muscles,  (9)  old  age,  acromegal}-,  and  sec- 
ondary osteoarthropathy. 

LORDOSIS. 

Lordosis  is  the  name  applied  to  the  increase  of  the  physiological 
curve  forward  in  the  lumbar  region.  This  exists  in  various  abnormal 
conditions,  and  the  amount  of  curve,  of  course,  varies  in  normal  indi- 
viduals from  those  who  have  a  very  flat  back  in  the  lumbar  region  to 
those  who  have  a  very  markedly  hollow  back.  In  certain  cases  in 
which  the  individual  is  perfectly  normal,  a  very  marked  lumbar  curve 
exists.  It  is  hardly  necessary  to  do  more  than  mention  the  various 
■conditions  in  which  lordosis  exists. 

1.  Lordosis  often  exists  in  connection  with  the  kyphosis  of  the  dor- 
sal spine  spoken  of  in  connection  with  round  shoulders ;  here  it  is  com- 
pensatory to  the  dorsal  curve  and  the  result  of  muscular  weakness. 

2.  Lordosis  also  exists  in  pregnant  women  and  often  in  persons  with 
large  abdomens,  due  to  accumulation  of  fat  or  to  distention,  as  in 
ascites  and  abdominal  tumors.  In  these  cases  it  is  simply  the  balanc- 
ing of  weight  by  which  the  centre  of  gravity  is  brought  over  the  centre 
of  support. 

3.  Increased  lumbar  curve  also  exists  as  the  result  of  training  in 
professional  gymnasts,  especially  in  backward  contortionists.  Such 
persons  habitually  walk  with  a  marked  degree  of  lordosis. 

4.  In  conditions  in  which  the  abdominal  or  the  back  muscles  are 
paralyzed,  the  attitude  of  lordosis  is  the  result  of  an  attempt  to  balance 
the  weight  of  the  upper  part  of  the  body  without  bringing  a  strain  upon 
the  muscles.     In  paralysis  of  the  abdominal  muscles  lordosis  exists. 

5.  In  Pott's  disease  of  the  lumbar  region  apparent  lordosis  may  be 
one  of  the  first  symptoms  to  be  noticed. 

6.  In  cases  of  double  congenital  dislocation  of  the  hip  lordosis  gen- 
erally exists,  because  the  point  of  support  of  the  femur  on  the  pelvis  is 
oftenest  back  of  the  acetabulum;  consequently  the  pelvis  rotates  on  a 
transverse  axis,  carrying  the  lumbar  spine  forward. 

7.  Lordosis  exists  in  many  cases  of  severe  rickets  on  account  of  the 
rotation  of  the  pelvis  on  a  transverse  axis,  as  will  be  described  in  speak- 
ing of  rickets. 


OTHER  DEFORMITIES  OF  SPINE  AND  THORAX.      385 

8.  In  hip  disease,  in  which  on  account  of  muscular  rigidity  or  ad- 
hesions one  leg  is  held  in  the  position  of  flexion,  lordosis  is  present. 
In  double  hip  disease  with  flexion  deformity  the  lordosis  may  be  exten- 
sive. Contraction  of  the  hip,  for  any  reason,  as  in  infantile  paralysis, 
causes  lordosis. 

9.  Lordosis  may  exist  in  coxa  vara,  both  secondary  to  the  distortion 
at  the  hip  and  as  another  manifestation  of  the  rhachitic  change. 

10.  In  spondylolisthesis  lordosis  is  very  marked. 

TreatDicnt.- — The  treatment  of  these  curves  is  necessarily  dependent 
upon  the  causative  conditions  and  attendant  circumstances. 


SPONDYLOLISTHESIS. 

The  name  spondylolisthesis  (^-o>(J;j/(^9,  a  vertebra,  and  o/.'^t^t^Vj^^,  a 
gliding)  refers  to  a  forward  subluxation  of  the  body  of  one  of  the  lower 
lumbar  vertebrae,  with  the  exception  of  one  recorded  case  in  which  the 
upper  part  of  the  sacrum  was  displaced  forward.  This  displacement 
has  ordinarily  been  described  as  a  dis- 
location ;  in  most  instances  it  hardly 
reaches  a  greater  degree  than  may 


Fig.  348.— Small  Pelvis  of  Prague  (Median  Sec- 
tion). Instance  of  slight  forward  displacement 
of  fifth  lumbar  vertebra.    (Neugebauer.) 


Fig.  349. — Breslau  Specimen.  Instance 
of  slight  forward  displacement  of 
the  fourth  lumbar  vertebra.  (Neu- 
gebauer.) 


be  described  by  the  name  subluxation.  Even  this  name  is  incorrect 
anatomically,  because  the  body  of  the  vertebrae  is  chiefly  affected, 
while  the  laminae  and  spinous  process  remain  practically  in  place.' 

'  Neugebauer:  "  Spondylolisthesis  et  Spondylizeme,"  Paris,  G.  Steinheil,  1S92. 
Critical  review,  description  of  specimens  and  cases,  complete  bibliography. — Kil- 
lian:  "Comment,  anat.  de  Sp.,"  Bonn,  1853;  "  Schilderung  neuer  Beckenformen," 
Mannheim,  1854. — Blake:  American  Journal  of  the  Medical  Sciences,  1867,  cvii., 
p.  285.— V.  P.  Gibney:  Medical  Record,  March  30th,  1SS9.— Lombard :  Boston 
Medical  and  Surgical  Journal,  August  20th,  1885.— Lovett :  Trans.  Amer.  Orth. 
Assn..  1S97. 
25 


386 


ORTHOPEDIC  SURGERY. 


Pathology. — The  essential  part  of  the  condition  seems  to  be  the 
slipping  forward  of  one  of  the  lower  lumbar  vertebral  bodies,  while  the 
vertebral  arches  remain  practically  in  place.     This  implies,  of  course, 


Fig.  350. — Pelvis  of  Moscow  (Median  Section). 
Instance  of  extreme  forward  displacement  of 
fifth  lumbar  vertebra.     (Neugebauer.) 


Fig.  351.— Specimen  from  the  Museum 
of  KoUiker  at  Wurzburg,  Showing 
Double  Defect  of  Vertebral  Arch. 
iXeug'ebauer.) 


an  increase  in  the  distance  between  the  body  and  the  spinous  process 
of  such  a  vertebra. 

The  commonest  form  of  the  displacement  is  subluxation  of  the  fifth 
lumbar  vertebra  in  relation  to  the  sacrum.     The  displacement  of  the 


Fig.  352.— Spondylolisthesis  due  to  Vertebral  Disease.     (Dr.  H.  B.  Gushing,  Johns  Hopkins 

Hospital.  I 

fourth  lumbar  vertebra  in  relation  to  the  fifth  is  next  in  frequency. 
The  displacement  forward  of  the  first  sacral  vertebra  in  relation  to  the 
rest  of  the  sacrum  has  been  recorded  once  only  (H.  von  Meyer,  Zurich 
specimen).     The  displacement  may  be  slight  or  extreme. 


OTHER  DEFORMITIES  OF  SPINE  AND  THORAX,     387 

Etiology. — Spondylolisthesis  is  recorded  as  affecting  women  more 
frequently  than  men,  and  comparatively  few  male  cases  have  been 
recorded.  It  occurs  almost  always  at  puberty  or  in  young  adult  life, 
and  the  majority  of  all  cases  give  the  account  of  a  severe  traumatism, 
occurring  most  often  during  childhood  or  near  puberty.  The  deformity 
may  follow  immediately  upon  the  accident,  or  it  may  develop  in  after- 


FlG.  353.— Case  of  Spond_vlolisthesis.     Woman,  thirty  years  old.     (Breisky.) 

years,  just  after  puberty  or  during  pregnancy.  Other  cases  are  to  be 
accounted  for  only  by  frequency  of  pregnancy  or  by  very  hard  work. 
In  some  cases  no  assignable  cause  can  be  found. 

Symptoms. — The  symptoms  by  which  the  diagnosis  must  be  made 
are  as  follows :  A  disturbance  of  equilibrium  resulting  in  a  faulty  car- 
riage, which  is  shown  chiefly  by  a  sharp  increase  in  the  lower  lumbar 
curve  in  even  the  mildest  cases.  The  spine  curves  forward  sharply 
from  the  sacrum,  and  this  gives  undue  backward  prominence  to  the 
crest  of  the  ilium  and  the  buttocks.  The  appearance  at  first  glance  is 
the  same  as  that  in  cases  of  double  congenital  dislocation  of  the  hip. 
Lateral  deviation  of  the  spine  may  be  present.     With  this  lordosis  goes 


388 


ORTHOPEDIC  SURGERY. 


a  diminution  of  the  obliquity  of  the  pelvis,  which  causes  flexion  of  the 
thighs. 

Vaginal  examination  shows,  of  course,  a  prominence  high  up  on  the 
posterior  wall  of  the  pelvis.  The  trunk  is  shortened  in  relation  to  the 
legs  on  inspection,  and  the  thorax  tends  to  approach  the  pelvis.  The 
affection  is  not  one  characterized  by  excessive  pain. 

The  differential  diagnosis  must  be  made  from  Pott's  disease,  double 
congenital  dislocation  of  the  hip,  and  rickets.  Rickets  must  be  recog- 
nized by  its  general  diagnostic  signs. 

Treatment. — The  most  successful  treatment  consists  in  fixation  of 
the  lower  spine  by  a  jacket  or  brace  until  the  fracture,  if  such  has  oc- 
curred, has  united  and  the  products  of  the  injury  have  been  absorbed; 


Fig.  354. — Side  View  of  Case  of  Spond\-l- 
olisthesis.     (Braun  v.  Fernwald.) 


Fig.  355, — Back  View  of  Same  Case. 


or,  if  heavy  weight-bearing  has  been  the  cause,  until  the  stretched  and 
weakened  tissues  have  resumed  as  normal  a  position  as  possible.  This 
period  must,  of  course,  last  for  months,  or  in  cases  of  great  deformity 
it  would  seem  as  if  a  fixation  support  must  be  permanent. 


OTHER  DEFORMITIES  OF  SPINE  AND   THORAX.      389 

DEFORMITIES   OF    THE    THORAX. 

Pigeon  Breast  (chicken  breast,  Huhnerbrust,  pectus  carinatum  or 
gallinatum,  poitrine  en  car^ne,  poitrine  de  pigeon,  etc.)  is  a  deformity 
more  or  less  common  in  children,  characterized  by  a  prominence  of  the 
sternum  and  cartilages  of  the  ribs  and  accompanied  by  an  increase  in 


Fig.  356.  —  Traumatic  Spondylolisthesis 
in  a  Young  Man  of  Eighteen. 


Fig.  357.— Funnel  Chest.     (J.  S.  Stone.) 


the  antero-posterior  diameter  of  the  chest  and  a  diminution  in  the  lat- 
eral. The  deformity  is  generally  most  marked  in  the  median  line,  but 
in  many  cases  the  prominence  affects  chiefly  the  ribs  of  one  side,  mak- 
ing a  unilateral  prominence  on  one  side  of  the  sternum.  It  is  due  to 
rickets  and  is  associated  often  with  nasal  or  pharyngeal  obstruction  in 
growing  children.  It  is  also  seen  in  a  marked  degree  in  dorsal  Pott's 
disease,  in  which  it  is  due  to  the  sinking  forward  of  the  upper  dorsal 
spine,  carrying  with  it  the  ribs.  In  slight  cases  the  deformity  is  prob- 
ably outgrown  spontaneously,  but  in  the  severer  cases  it  may  last  into 
adult  life. 


390 


ORTHOPEDIC  SURGERY. 


The  treatment  consists  in  children  in  a  combination  of  gymnastic 
and  respiratory  exercises  to  expand  and  develop  the  lateral  parts  of  the 
chest.  As  a  type  of  these  exercises  may  be  mentioned  a  useful  one,  in 
which  the  patient  lies  on  the  back  and,  with  strong  pressure  made 
downward  on  the  deformity,  deep  inspirations  are  taken. 

Funnel  Chest  (funnel  breast,  Trichterbrust,  pectus  excavatum,  tho- 
rax-en-entonnoir)  is  a  name  applied  to  a  deformity  in  which  the  sternum 
and  costal  cartilages  are  depressed  below  their  normal  level.     The  de- 


FiG.  358.— Congenital  Elevation  of  the  Scapula. 

formity  is  as  a  rule  asymmetrical,  and  in  its  lighter  degrees  is  not  un- 
common. It  is  more  marked  in  males  than  in  females,  and  but  little  is 
known  of  the  cause  of  the  affection.  In  many  cases  it  apparently  is 
congenital,  and  in  a  mild  degree  is  sometimes  seen  in  connection  with 
Pott's  disease.  No  satisfactory  treatment  has  been  formulated  beyond 
general  gymnastic  measures,  among  which  may  be  mentioned  forced 
inflation  of  the  chest. 

Congenital  Deformities. — Other  deformities  of  the  thorax  of  con- 
genital origin  need  only  to  be  mentioned.  Among  these  are  absence  or 
a  defective  formation  of  the  ribs,  a  condition  generally  associated  wath 
lateral  curvature  of  the  spine,  the  presence  of  cervical  ribs,  and  anomalies 


OTHER  DEFORMITIES  OF  SPINE  AND   THORAX.      391 

or  absence  of  the  pectoral  and  other  muscles.  Defective  formation  or 
absence  of  the  clavicle  has  been  reported,  and  malformation  of  the 
scapula  is  sometimes  seen. 

Congenital  Elevation  of  the  Scapula  (Sprengel's  deformity,  ange- 
borener  Hochstand  des  Schulterblattes). — This  condition  is  a  somewhat 
unusual  congenital  deformity,  in  which  one  scapula  is  raised  in  its  rela- 
tion to  the  thorax  and  clavicle  and  also  to  the  opposite  scapula.  The 
scapula  is  not  only  raised,  but  generally  so  rotated  that  its  lower  angle 
approaches  the  spine.  Scoliosis  is  likely  to  exist  in  connection  with  it, 
and  in  some  cases  asymmetry  of  the  face  and  skull  has  been  noted ;  the 
affection  is  rarely  bilateral.'  One  or  more  of  the  scapular  muscles  may 
be  absent  and  bony  anomalies  are  frequent.  In  one  class  of  cases  a 
bridge  of  bone  connects  the  scapula  and  the  vertebral  column ;  in  an- 
other class  there  is  a  long  piece  of  bone  projecting  upward  from  the 
superior  border  of  the  scapula,  but  not  articulating  with  or  attached  to 
the  vertebrae.  In  other  cases  there  is  no  bony  outgrowth  and  no  defi- 
ciency of  muscles.  In  some  cases  the  projecting  upper  border  of  the 
scapula  is  so  noticeable  in  its  elevated  position  that  it  is  mistaken  for 
an  exostosis." 

The  etiology  is  obscure.  Certain  of  the  cases  are  evidently  to  be 
classed  with  other  congenital  malformations.  The  theory  of  intra-uter- 
ine  pressure  and  the  persistence  of  a  position  of  the  scapula  natural  to 
a  certain  period  of  foetal  life  have  been  urged  as  the  cause  of  some  of 
the  cases. ^ 

In  cases  seen  during  childhood  extensive  division  of  the  shortened 
muscles  holding  the  scapula  in  its  abnormal  position  is  to  be  advised, 
and  the  removal  of  any  bony  bridge  or  projection.  Marked  improve- 
ment may  thus  be  obtained.  In  older  cases  no  operative  treatment  is 
advisable.^ 

^  Centralbl.  f.  Chir. ,  1902. 

-Wilson  and  Rugh  :  Annals  of  Surgery,  April,  1900. 

^Hibbs  and  Correll — Lowenstein :  Zeitsch.  f.  Orth.,  xi.,  i,  p.  40. 

■* Freiberg:  Annals  of  Surgery,  May,  1889. 


CHAPTER    XIII. 
TORTICOLLIS. 

Definition.  —  Etiology. — Pathological    anatomy. — Symptoms. — Diagnosis. — Prog- 
nosis.— Treatment  (Mechanical. — Operative). 

DEFINITION. 

The  name  torticollis  is  given  to  that  distortion  of  the  head  which 
causes  it  to  be  held  awry,  and  this  condition  is  either  constant  or  inter- 
mittent. 

The  other  names  by  which  this  affection  is  known  are  wry -neck, 
caput  obstipum,  collum  distortum,  cou  tortu,  Schiefhals. 

ETIOLOGY. 

Torticollis  may  be  congenial  or  acquired.' 

I.  Congenital  Torticollis. 

{a)  It  may  exist  in  connection  with  other  deformities,  such  as  club- 
foot and  similar  malformations.  In  these  cases  it  seems  proper  to  at- 
tribute its  existence  to  those  intra-uterine  conditions  causing  other  de- 
formities. 

{b)  Abnormal  pressure  of  the  uterus  seems  to  be  accountable  for 
another  class  of  cases  in  which  the  cranium  and  face  on  the  affected 
side  are  smaller  at  birth. 

{c)  Amniotic  adhesions  are  spoken  of  as  a  cause. 

(d)  Inflammation  of  the  muscles  seems  to  be  proved  by  the  patho- 
logical findings  in  certain  cases  and  must  be  mentioned  as  an  occasional 
cause. 

{e)  Arrest  of  the  development  of  the  muscles  due  to  an  affection  of 
the  nerves  or  nerve  centres  must  be  spoken  of  as  a  cause  often  ad- 
vanced to  account  for  torticollis.^ 

(/")  Rupture  of  the  sterno-mastoid  muscle  occurring  at  birth  has 

^  Trans.  Am.  Orth.  Assn.,  iv..  p.  293. — P.  Redard  :  "  Le  Torticolis,"  etc, 
Paris,  1898  (full  bibliography). 

-Osier:  N.  Y.  Med.  Journ.,  December  12th,  1S91.— Golding  Bird:  Guy's 
Hosp.  Rep.,  1890. — Shaffer:  Trans.  Am.  Orth.  Assn..  vol.  iv.,  p.  305. 

392 


TORTICOLLIS.  393 

been  mentioned '  as  a  cause  of  torticollis,  and  undoubted  cases  have 
been  observed  where  torticollis  has  followed  partial  rupture  of  the 
sterno-mastoid  at  childbirth.  Experiments,  however,  upon  rabbits 
producing  hrematomata  of  the  sterno-mastoid  gave  negative  results. 
Furthermore,  torticollis  has  not  followed  the  hsematomata  from  rupture 
of  the  sterno-mastoid  at  birth  in  a  number  of  cases  carefully  watched 
by  several  observers. 

(V)  Imperfections  in  the  atlas  and  cervical  vertebree  have  in  some 
reported  cases  been  the  cause  of  congenital  torticollis. 


2.  Acquired  Torticollis. 

As  the  causes  of  the  affection  may  be  mentioned : 

{a)  Cicatricial  contraction  of  the  skin  or  deeper  tissues. 

{b)  Traumatism  to  the  neck  and  head. 

(<r)  Dislocation  of  the  upper  cervical  vertebrae.* 

id')  Inflammation  of  the  muscle  (rheumatic  torticollis  or  acute  or 
chronic  myositis). 

{/)  Reflex  irritation  of  the  muscles  in  caries  of  the  spine  is  well 
known,  and  in  vertebral  articular  rheumatism  this  distortion  may  fol- 
low. Torticollis  may  also  be  seen  in  inflammation  of  the  cervical  lymph 
nodes  or  with  deep  cervical  abscesses,  retropharyngeal  abscesses,  in- 
flammations of  the  ear,  parotitis,  adenoid  vegetations  in  the  nasophar- 
ynx, tumors  of  the  neck,  and  cerebral  lesions.  Neuralgia  of  the  spinal 
accessory  or  cervico-brachial  nerves  may  be  accompanied  by  torticollis.^ 

(/)  Difference  in  the  plane  or  power "  of  vision  of  the  eyes. 

{g)  Lateral  curvature. 

(Ji)  Voluntary  habit^  (physiological  torticollis). 

(?)  Occupations  in  which  the  overuse  of  one  sterno-mastoid  muscle 
is  necessary,  as  in  the  case  of  a  factory  girl  who  was  continually  com- 

'Jeannel:  "  Encyc.  Int.  de  Chir.,"  18S6,  v.,  777. — Busch  :  Berl.  klin.  Woch., 
1873,  xxxvii. — Stromcyer:  "  Handb.  derChir. ,"  ii. ,  4. — Fischer:  Deutsch.  Chir., 
1880,  Lief.  43. — Volkmann :  Cent.  f.  Chir.,  18S5,  xiv.,  233. — Witzel :  Deutsch. 
Zeit.  f.  Chir.,  1883,  xviii.,  534. — Petersen:  Zeitsch.  f.  orth.  Chir.,  i.,  L.  i.  113. — 
Fabry:  Inaug.  Diss.,  Bonn,  1885.— Cent.  f.  Chir.,  1895,  No.  i. — Deutsches  Arch, 
f.  Chir.,  1882,  p.  181;  Cent,  fur  Gyn.,  1886,  No.  9.— Bouchut :  "  Traite  Prat.de 
Mai.  des  Nouv.  Nees,"  Paris,  1750. — Archiv  f.  Kinderheilicunde,  1891,  Bd.  xii.,  5 
and  6.— N.  Y.  Med.  Rec,  February  27th,  1886.— Petersen :  Cent.  f.  Gyn.,  1896, 
No.  48. 

'■'Walton:  Bost.  Med.  and  Surg.  Journ.,  cxlix.,  17,  445. 

^Dollinger:  Pester  med.  chir.  Presse,  1889,  No.  48. 

•*  Bradford :  Trans.  Am.  Orth.  Assn.,  1889,  vol.  i.,  p.  46. — Lovett :  Trans. 
Am.  Orth.  Assn.,  1889,  vol.  i. — Gould:  American  Medicine,  March  26th,  1904. — 
H.  W.  Kilburn :  Boston  Med.  and  Surg.  Journ.,  March  24th,  1904. 

^Mellet:  "  Manuel  Prat.  d'Orth.,"  Paris,  1844. 


394  ORTHOPEDIC  SURGERY. 

pelled  by  her  work  to  turn  the  head  to  one  side,  or  in  the  case  of  a  per- 
son carrying  heavy  loads  continually  on  one  shoulder. 

(/)  Rickets. 

(k)  Pott's  disease  of  the  cervical  vertebrae. 

(/)  Injury  to  the  nerve  centres  at  the  time  of  birth.  The  affection 
may  rarely  involve  both  sides,  as  in  a  case  figured  by  Whitman.' 

(;«)  Paralysis  of  the  spinal  accessory  nerve  from  such  causes  as 
rheumatism  or  trauma  as  well  as  anterior  poliomyelitis  ^  and  the  mus- 
cular dystrophies.^ 

Spasmodic  Torticollis. — In  this  class  are  included  those  cases  which 
arise  from  nerve  irritation.  This  form  may  be  central  and  occur  in 
the  distribution  of  the  spinal  accessory  nerve,  or  it  may  be  the  local 
manifestation  of  a  more  general  nervous  irritation  as  in  spinal  irritation. 
In  some  cases  of  the  spasmodic  form,  the  affection  is  closely  allied  to 
writers'  cramp,  spasmodic  tic  of  the  face,  etc.,  and  in  one  case  observed 
there  was  a  nodding  motion  to  the  head.  The  spasm  in  this  class  of 
cases  can  be  either  tonic  or  clonic. 

Frequently  no  definite  cause  can  be  found  to  explain  the  occurrence 
of  this  form,  but  it  is  evidently  the  result  of  general  malnutrition  or 
general  nervous  disturbance  having  this  as  a  local  manifestation.  Not 
infrequently  in  these  cases  there  will  be  found  a  definite  exciting  cause, 
such  as  fright,  grief,  etc.  In  this  class  might  be  included  the  "  torti- 
colis  mental"  of  Brissaud  "  and  Bompaire.^ 

Many  of  the  above  causes  seem  each  to  be  but  one  out  of  many  fac- 
tors. In.  a  large  percentage  of  cases  there  will  be  found  to  be  a  neu- 
rotic family  or  personal  history ;  also  the  general  condition  seems  to 
have  a  very  considerable  influence.  Many  cases  occur  after  severe 
overwork,  in  this  particular  bearing  a  close  analogy  to  professional 
cramp  or  spasm. 

PATHOLOGY. 

The  pathological  condition  existing  in  congenital  torticollis  has  been 
•demonstrated  by  autopsy  and  by  pieces  of  muscle  removed  at  operation. 
In  some  instances  the  contracted  muscle  appears  normal,  but  more 
often  the  muscular  substance  is  replaced  by  fibrous  tissue.  This  may 
occur  in  small  patches  °  or  the  whole  muscle  may  be  transformed  into  a 
tendinous  band.  In  the  majority  of  cases  of  fibrous  degeneration  of 
the  muscle  it  is  adherent  to  the  sheath,  and  in  some  instances  muscle 
and  sheath  are  fused  in  one  fibrous  band. 

'Bradford  and  Lovett :  "  Orth.  Surg.,"  2d  ed.,  p.  632,  Fig.  272. 

'^  Hoffa  :  "  Orth.  Chir. ,"  4th  ed. 

^  Dejerine  and  Flandre,  quoted  by  Redard  :  "  Le  Torticolis,"  1898,  p.  40. 

*  Union  Medicale,  1894,  p.  161. 

*"  Torticolis  Mental,"  These  de  Paris,  1894. 

•^Volkmann:  Cent.  f.  Chir.,  1885,  No.  14.— Vallert:  Ibid.,  1890,  No.  38. 


TORTICOLLIS.  395 

The  sternal  part  of  the  muscle  is  more  often  involved  than  the  cla- 
vicular. The  changes  described  are  to  be  classed  as  fibrous  myositis, 
the  reason  for  which  has  not  yet  been  formulated.  Other  muscles 
besides  the  sterno-mastoid  may  be  degenerated,  and  all  of  the  struct- 
ures on  that  side  of  the  neck  are  of  course  shortened.  Changes  to  be 
classed  as  perimyositis  have  been  demonstrated  in  certain  cases.' 
Shortening  of  the  muscle  on  the  affected  side  may  amount  to  several 
centimetres." 

Secondary  changes  occur  in  long-continued  torticollis.  The  most 
marked  is  asymmetry  of  the  face ;  a  deviation  of  the  line  of  the  nose 
from  a  right  angle  to  the  line  of  the  eyes  is  noticed ;  furthermore,  the 
distances  from  the  outer  point  of  the  two  eyes  to  the  outer  corners  of 
the  mouth  are  not  the  same,  while  the  cheek  on  the  contracted  side  is 
less  prominent  and  the  features  on  the  affected  side  of  the  face  are 
smaller  than  those  upon  the  other  side.  This  asymmetry  diminishes  if 
the  deformity  is  corrected  early.  Asymmetry  of  the  skull  may  also  be 
found,  as  well  as  a  diminished  size  of  the  cerebral  hemisphere '  on  the 
affected  side.  The  carotid  artery  of  the  affected  side  has  been  in 
certain  cases  found  smaller.^ 

This  asymmetry  of  the  face  may  occur  in  acquired  torticollis,  and  it 
may  be  present  at  birth  in  congenital  cases.  It  may,  on  the  other 
hand,  be  present  at  birth  without  the  existence  of  torticollis. 

Lateral  curvature  of  the  spine  will  result  from  long-continued  torti- 
collis, and  a  difference  in  the  length  of  the  clavicles  has  been  noted. 

SYMPTOMS. 

Acute  Torticollis. — In  the  acute  form  the  history  is  that  of  an  acute 
muscular  rheumatism  with  some  constitutional  disturbance  and  sudden 
onset  with  a  great  deal  of  pain  on  movement  of  the  head,  and  the  head 
is  held  to  one  side.  The  acute  stage,  however,  lasts  but  a  short  time 
and,  in  general,  pain  in  wry-neck  is  not  a  permanent  symptom.  The 
chief  discomfort  from  wry-neck  is  the  disfigurement  which  is  always 
noticeable  and  never  to  be  concealed.  The  position  assumed  by  the 
head  is  more  or  less  typical  and  is  described  farther  on.  The  chronic 
form  may  develop  from  the  acute  form. 

'  Archiv.  d.  Pediatric,  1S90,  No.  i. 

^  Orth.  Trans.,  iv.,  p.  305. 

^'Greffie:  Montpellier  Med  ,  November  i6th,  1890.— Broca:  Bull.  Med.,  1894, 
No.  42,  p.  493. 

•*  Osier :  N.  Y.  Med.  Journ. ,  December  12th,  1891.— Golding  Bird  :  Guy's  Hosp. 
Rep.,  xlvii.,  1S90. — Krummacher:  Cent,  f  Chir.,  1889,  No.  xii. — Beely  :  Zeitsch. 
f.  orth.  Chir.,Bd.  ii.— Meinhard  Schmidt:  Cent.  f.  Chir. ,  July  26th,  1890.— Fal- 
kenburg:  Deutsch.  Zeit.  f.  Chir.,  1885,  xix.,  338. — Bouvier:  "Leg.  Clin,  sur  les 
Mai.,"  etc.,  Paris,  1858. — Stromeyer:  "  Handb.  der  Chir.,"  ii.,  p.  4,  1864. 


39^ 


ORTHOPEDIC  SURGERY. 


Congenital  Torticollis.— The  position  held  by  the  head  varies  neces- 
sarily with  the  muscles  affected.  When  the  sterno-cleido-mastoid  is 
attacked,  the  ear  of  the  affected  side  is  brought  near  to  the  sternum 
and  the  face  slightly  rotated  to  the  opposite  side.  If  the  trapezius  or 
posterior  muscles  are  also  affected,  the  head  will  also  be  drawn  back, 
the  chin  elevated  above  its  normal  level,  and  the  features  on  the  side  of 
the  spasm  drawn  below  those  on  the  opposite  side.  In  addition  to 
these  muscles,  the  platysma,  the  scaleni,  splenii,  and  other  deep  mus- 
cles of  the  neck  are  sometimes  affected,  and  modify  more  or  less  the 
position  of  the  head.  The  attitude  is  sometimes  so  peculiar  as  to  ren- 
der it  difficult  to  determine  exactly  what  muscles  are  affected.  On 
palpation  certain  muscles  will  be  found  to  be  hard  to  the  touch  and 
others  ilaccid.  Rotation  of  the  head  is  free  up  to  a  certain  limit,  vary- 
ing in  extent.  It  is  not  possible  to  move  the  head  in  a  direction  against 
the  contraction  or  spasm,  and  a  persistent  effort  may  cause  considerable 
pain. 

Spasmodic  Torticollis. — The  intermittent  form  of  torticollis  is  not 
infrequent.  It  is  due  to  imperfect  muscular  balance  from  overstrain  of 
certain  groups  of  muscles  which  are  affected  by  spasmodic  attacks. 
This  condition  is  not  unlike  that  noted  in  writers'  cramp  and  similar 


Fig.  359-- 


-Ocular  Torticollis, 
position  of  head. 


Habitual 


Fig.  360. —Ocular   Torticollis;    Back 
View.     Habitual  position. 


muscular  disturbances  seen  in  occupation  neuroses.  At  times  the  head 
can  be  held  in  a  proper  position,  but  locomotion  or  any  excitement  or 
the  apprehension  of  being  observed  may  produce  such  a  contraction 
of  the  head  that  it  will  be  twisted  violently  to  one  side  and  rotated  to 
an  extreme  limit.     A  slight  pressure  of  the  hand  steadying  the  head 


TORTICOLLIS. 


597 


will  ordinarily  correct  it,  but  when  the  muscular  contraction  becomes 
excited,  great  force  is  required  to  hold  the  head  in  place. ,  In  some  cases 
the  contraction  may  be  slow  and  steadily  increase  to  its  maximum.  In 
a  recumbent  position  the  contraction  does  not  ordinarily  take  place. 
It  usually  disappears  during  sleep.     The  spasm  is  sometimes  tonic  and 


Fig.  361. — Torticollis  Showing  Contraction 
of  the  Right  Sterno-inastoid. 


Fig.  362. — Torticollis  due  to  Cervical  Pott's 
Disease. 


sometimes  clonic,  and  sometimes  pain  is  excited  by  the  muscular  con- 
traction. It  is  usually  confined  to  the  muscles  of  one  side  (tic  gira- 
toire).  It  may  be  accompanied  by  severe  attacks  of  pain,  and  may  in- 
volve the  muscles  of  the  back.  Slight  twitchings  of  the  muscles  are 
sometimes  observed  for  some  time  previous  to  an  outbreak  of  the  spas- 
modic condition. 

DIAGNOSIS. 

There  is  no  difficulty  in  recognizing  the  deformity  called  wry -neck. 
The  head  is  twisted  to  one  side,  the  chin  being  to  the  right  or  left  of 
the  sterno-clavicular  notch,  while  the  face  is  turned  to  one  side  and 
partly  upward.  The  shoulders  are  held  obliquely  to  the  trunk,  twisted, 
in  order  to  bring  the  face  so  far  as  possible  in  a  vertical  line.  Certain 
of  the  muscles,  frequently  the  sterno-cleido-mastoid,  are  felt  hard  on 
palpation;  some  rotation  of  the  head  is  possible,  but  perfectly  free 
rotation  of  the  head  is  checked  by  the  contracted  muscles. 

A  diagnosis  of  the  cause  and  situation  of  wry-neck  is  more  difficult. 


398  ORTHOPEDIC  SURGERY. 

as  well  as  an  attempt  to  distinguish  it  from  other  affections  which  giv^e 
rise  to  this  malformation,  a  matter  which  is  of  great  importance.  Such 
are  disease  of  the  cervical  vertebra,  enlarged  cervical  glands,  cervical 
abscess,  and  stiff  neck  from  ordinary  cold. 

The  diagnosis  between  anterior  and  posterior  torticollis  (or  torti- 
collis due  to  contraction  of  the  anterior  muscles,  chiefly  the  sterno- 
cleido-mastoid,  and  that  due  to  the  contraction  of  the  posterior  muscles, 
the  trapezius  and  splenius  capitis,  etc.)  is  to  be  based  on  palpation 
chiefly. 

Palpation  also,  with  a  clinical  history  of  paralysis  and  the  evidence 
of  paralysis  elsewhere,  is  suiiflcient  usually  to  determine  the  diagnosis 
of  paralytic  torticollis. 

Torticollis  dependent  upon  enlarged  and  inflamed  glands  can  usually 
be  recognized  by  the  evidence  of  glandular  enlargement. 

There  is  ordinarily  little  difficulty  in  recognizing  the  common  acute 
wry -neck.  Its  course  is  acute,  the  deformity  appears  suddenly,  and  it 
is  usually  accompanied  by  pain.  Improvement  is  to  be  noticed  in  a 
comparatively  short  time. 

For  the  diagnosis  of  congenital  torticollis  from  that  due  to  Pott's 
disease  the  reader  is  referred  to  the  chapter  on  Pott's  disease,  but  it 
may  be  said  that  in  the  latter  there  is  greater  rigidity,  and  this  involves 
all  the  muscles  of  the  neck,  and  particularly  the  posterior  groups.  The 
pain  elicited  by  attempts  to  twist  the  head  is  greater.  When  a  patient 
with  cervical  caries  attempts  to  lie  down  or  turn  over  the  head  is  in- 
stinctively steadied  with  the  hand,  while  in  true  torticollis  this  is  not 
so  constant  a  symptom. 

Cases  of  posterior  torticollis,  i.e.,  that  form  described  by  Delore, 
involving  the  posterior  muscles  of  the  neck,  resulting  from  vertebral 
rheumatism,  is  rare.  It  can  be  recognized  by  the  absence  of  contrac- 
tion of  the  sterno-mastoid  and  the  history  of  the  case. 

PROGNOSIS. 

The  acute  idiopathic  wry-neck  due  to  muscular  inflammation  runs  a 
short  course  and  tends  naturally  to  recovery,  though  in  a  few  cases  it 
may  become  chronic.  Torticollis  due  to  abscess  of  the  cervical  glands 
terminates  with  the  complete  discharge  of  the  abscess  as  a  rule.  Inter- 
mittent spasmodic  torticollis  may  become  cured  spontaneously,  or  may, 
as  is  more  common,  remain  without  change  for  many  years.  Congeni- 
tal forms  of  torticollis  and  the  common  acquired  form  (associated  with 
muscular  contraction  which  has  become  chronic  and  developed  fibrous 
muscular  degeneration)  demand  surgical  intervention.  Xo  constitu- 
tional disturbance  follows  this  affection,  which  is  more  distressing  on 
account  of  the  unsightliness  than  from  any  actual  discomfort. 


TORTICOLLIS. 


399 


The  deformity  is  one  which  is  eminently  curable  by  surgical  inter- 
vention. Complete  correction  and  permanent  cure  are  possible  in  all 
cases  except  in  the  intermittent  form,  which  is  dependent  upon  a  gen- 
eral depressed  state  of  the  nervous  system,  in  which  a  cure  cannot 
always  be  promised. 

TREATMENT. 

In  acute  torticollis  due  to  the  inflammation  of  the  muscles,  the 
treatment  is  largely  the  alleviation  of  the  symptoms.  This  is  best  done 
by  the  application  of  moist  heat.  Rest  of  the  head  and  antifebrile  con- 
stitutional treatment  are  of  course  advisable  when  there  is  any  fever. 

Torticollis  due  to  cervical  Pott's  disease  is  treated  according  to  the 
principles  of  treatment  of  that  affec- 
tion, and  will  disappear  with  the  im- 
provement of  the  bone  disease.     Tor- 
ticollis   due    to    muscular    contraction 


Fig.  363.— Torticol 


I^rLicf,  Front  View. 


Fig.  364. ^Torticollis   Brace   Applied, 
Back  View. 


secondary  to  cervical  abscesses  or  enlarged  glands  is  corrected  by 
the  proper  treatment  of  cervical  abscess.  Torticollis  due  to  an  affec- 
tion of  the  eye  is  to  be  corrected  by  proper  ocular  treatment. 

Congenital  Torticollis. — The  treatment  of  wry-neck  due  to  perma- 
nent muscular  contraction  is  either  operative,  or  purely  mechanical,  or 
mechanical  and  operative. 

Mechanical  Treatment. — Mechanical  treatment  without  the  aid 
of  operation  is  usually  unsuccessful  or  but  partially  successful,  except  in 
the  liirhtest  cases. 


400  ORTHOPEDIC  SURGERY. 

Massage  and  passive  manipulation  are  of  value  in  mild  cases  in  con- 
nection with  mechanical  treatment. 

A  simple  form  of  appliance  is  that  introduced  by  Buckminster 
Brown,  of  Boston  (Chapter  XXI.,  24).  A  stiff  wire  collar  passes 
around  the  neck,  furnished  with  a  plate  under  the  chin,  arranged  so  as 
to  press  on  the  deflected  side  of  the  chin.  Pressure  is  also  arranged  to 
be  applied  to  the  inclined  side  of  the  head  behind  the  ear.  The  wire 
collar  is  attached  to  a  ring  which  rests  upon  the  shoulder,  and  is  fur- 
nished with  arms  which  pass  down  the  back. 

oMechanical  treatment  is  to  be  regarded  as  of  value  chiefly  in  retain- 
ing the  correction  obtained  by  operative  measures. 

Oper.\tive  Treatment. — Before  the  introduction  of  aseptic  sur- 
gery the  dread  of  deep  suppuration  of  the  cervical  fascia  certain  to  fol- 
low deep  dissection  favored  the  employment  of  subcutaneous  tenotomy 
of  the  sterno-cleido-mastoid  tendon,  followed  by  mechanical  stretching. 
Failure  or  imperfect  results  followed  these  imperfect  methods.  Sub- 
cutaneous tenotomy  is  to  be  rejected  as  dangerous  if  freely  employed 
and  lacking  precision.  Open  incision  of  the  contracted  muscular  tissues 
can  be  both  precise  and  thorough,  and  the  results  are  entirely  satisfac- 
tory. 

In  the  usual  form  of  torticollis  the  contracted  muscle,  the  sterno- 
mastoid,  is  easily  attached.  Division  is  made  (i)  either  at  the  sternal 
and  clavicular  insertion,  or  (2)  at  its  origin  at  the  mastoid  process. 

Division  at  the  Stcrno-Cleido  Insertion. — An  incision  of  the  skin  is 
made  parallel  to  the  clavicle,  laying  bare  the  insertion  of  the  muscle. 
The  incision  should  be  sufficiently  long  to  expose  the  whole  attachment, 
as  it  is  desirable  that  no  undivided  fibres  remain.  It  is  desirable  that 
the  resulting  scar,  if  any,  should  be  concealed  below  the  clothing  and 
not  appear  in  the  neck.  This  can  be  accomplished  by  dividing  the  skin 
W'hile  the  head  is  bent  forward,  cutting  down  upon  the  clavicle  and 
drawing  the  elastic  skin  slightly  upward  from  the  chest.  If,  after  the 
division,  the  head  is  strongly  retracted,  as  is  desirable  to  give  the  mus- 
cular attachments  necessary  prominence,  the  incised  skin  will  gape  suffi- 
ciently above  the  clavicle  to  give  room  for  division  of  the  muscle,  aided 
if  necessary  by  hook  retraction  of  the  skin.  The  tissues  to  be  divided 
are  to  be  carefully  freed  from  all  overlying  tissue  and  a  director  passed 
under  the  sternal  tendon,  care  being  taken  that  the  director  is  passed 
completely  under  and  not  through  the  muscular  attachment. 

It  is  usually  necessary  that  both  the  clavicular  and  sternal  attach- 
ments of  the  muscle  be  divided  to  prevent  any  possibility  of  relapse, 
and  for  this  reason  the  skin  incision  should  be  made  sufficientl}^  long  to 
give  ample  room.  With  ordinary  care  there  is  no  danger  of  dividing 
the  vessels,  although  they  are  in  close  proximity. 

The  external  jugular  is  so  superficial  that  it  can  always  be  seen.     It 


TORTICOLLIS. 


401 


^tV 


usually  lies  farther  to  the  outside  than  the  line  of  incision.  The  inter- 
nal jugular  and  the  artery  are  separated  from  the  field  of  operation  by 
the  deep  fascia,  and,  if  the  sterno-cleido  muscle  is  made  prominent  and 
stretched  by  placing  the  head  backward,  the  muscular  insertions  can  be 
completely  divided  without  great  risk. 

In  open  incision  there  is  danger  of  wounding  the  internal  jugular 
vein;  deaths  from  this  cause  have  been  reported  after  tenotomy.  The 
writers  would  record  one  case  in  their  experience  in  which  the  internal 
jugular  was  wounded  in  an  open  incision.  It  was  tied  and  no  untOAvard 
results  followed,  the  patient  making  a  perfect  recovery.  The  vein  lies 
under  the  deep  fascia,  and  can  be 
avoided  in  open  incision  if  the 
neck  be  not  stretched  and  care  be 
taken  not  to  open  the  deep  cervi- 
cal fascia. 

^lastoid  Division  of  the  Stcrno- 
Cleido-Mastoid  Muscle. — A  divis- 
ion of  the  sterno-mastoid  at  its 
origin  from  the  mastoid  process 
has  been  advocated  on  the  ground 
that  the  incision  is  away  from  the 

vessels  and  that  the  resulting  scar  '  '  "^ 

is  in  a  less  noticeable  region.     For 
this  division  an  oblique  skin  incis- 
ion   is    made    along    the    sterno- 
mastoid,  beginning  behind  the  ear 
and  extending  nearly  to  the  middle 
of  the  muscle.     The  muscular  or- 
igin  is   much    thicker    than    the 
clavicular  insertions  and  care  will 
be   needed    to   divide  the   muscle 
thoroughly.     The  muscle  is    also 
divided  through  an  oblique  incis- 
ion along  the  lower  third  of  the  muscle.     The  incision  should  be  a 
free  one  if  the  division  is  complete.     The  muscle  is  thick  in  this  region, 
but,  being  prominent  and  superficial,  is  easily  separated  from  other 
tissues. 

The  choice  as  to  incision  will  rest  with  the  judgment  of  the  surgeon. 
The  division  of  the  sternal  and  clavicular  attachment  appears  to 
have  certain  advantages,  in  that  the  muscle  is  more  nearly  tendinous 
than  in  the  other  portions  and  can  therefore  be  divided  more  satis- 
factorily. 

Whatever  incision  is  employed,  especial  care  should  be  taken  to 
promote  the  healing  of  the  skin.     A  buried  skin  suture  should  be  em- 
26 


Fig.  365.— Result  of  Open  Incision  One  Year 
after  Operation  in  a  Girl  of  Sixteen.  Shows 
also  the  unequal  development  of  the  face. 


402 


ORTHOPEDIC  SURGERY. 


ployed,  and  the  wound  protected  by  silver  foil  from  the  irritation  of  the 
dressing. 

The  neck  and  chest  are  covered  with  sheet  wadding  and  the  head  is 
fixed  in  an  overcorrected  position  by  plaster  bandages  applied  around 
the  head,  shoulders,  and  thorax.  A  window  can  be  cut  over  the  incis- 
ion for  the  examination  of  the  wound,  but  under  proper  precautions  the 
wound  can  be  expected  to  heal  rapidly  and  to  need  no  further  dressing. 
It  is  unnecessary  for  the  patient  to  remain  in  bed  longer  than  a  few 
days,  if  satisfactory  plaster  fixation  is  furnished.     Under  some  circum- 


^^K 

^^^^m. 

P 

t"'' 

! 

1 

- 

„.  .   ^ 

Fig.  366.  — Posterior  Torticollis  Before  Forc- 
ible Straightening. 


Fig.  367. — After  Operation. 


Stances,  however,  it  is  desirable  to  avoid  a  cumbersome  plaster  helmet, 
and  recumbency  for  two  weeks  is  preferred.  It  is  necessary  that  thor- 
ough overcorrection  should  be  furnished  during  the  period  of  healing. 
This  can  be  accomplished  by  securing  the  patient  on  a  gas-pipe  frame, 
with  the  shoulders  firmly  fastened.  Three  strips  of  adhesive  plaster 
with  a  long  strip  of  webbing  sewed  to  one  end  of  each  are  applied  to  the 
patient's  head — one  across  the  forehead,  with  the  tape  arranged  to  pass 
under  the  head;  a  second  on  the  side  operated  upon,  with  the  tape 
passing  over  the  head ;  the  third  on  the  opposite  side,  with  the  tape 
passing  under  the  chin.  If  light  weights  are  attached  to  the  ends  of 
the  tapes  and  pass  over  sand  bags  placed  at  the  sides  of  the  face,  a  cor- 
recting pulling  force  can  be  exerted  in  three  directions — one  pulling  the 
chin  to  the  side  not  operated  upon,  the  second  inclining  the  long  axis 
of  the  head  in  a  direction  the  reverse  of  its  former  inclination,  and  the 
third  rotatine:  the  face  toward  the  unaffected  side.     This  method  of  fix- 


TORTICOLLIS.  403 

ation  will  be  found  of  use  where  it  is  difficult  to  secure  the  adequate 
amount  of  overcorrection  of  the  deformity  at  the  time  of  operation.  It 
should  be  borne  in  mind  that  not  only  correction  but  overcorrection,  at 
or  immediately  after  the  operation,  is  necessary  to  prevent  a  relapse, 
which  will  follow  to  a  greater  or  less  degree  if  contracted  tissues 
remain. 

After  the  wound  is  entirely  healed  the  patient  should  wear,  for  from 
three  to  six  months,  a  retaining  appliance  holding  the  head  in  an  over- 
corrected  position.  This  can  be  a  plaster  bandage,  a  leather  moulded 
on  a  plaster  form,  or  a  steel  appliance  (Chapter  XXI.,  34). 

Massage  will  aid  in  the  recovery  of  muscular  tone. 

The  results  of  the  correction  of  torticollis  by  open  division  are 
extremely  satisfactory.  The  asymmetry  of  the  face  becomes  more 
noticeable  after  correction  than  it  was  in  the  deformed  position,  but  in 
children  disappears  gradually  if  the  corrected  position  is  retained. 
Resection  of  the  lower  two-thirds  of  the  sterno-mastoid  muscle  has  been 
advocated,  on  the  ground  that  after-treatment  is  shortened  and  relapse 
prevented.  It  seems  unnecessary,  however,  as  it  leaves  a  long  scar,  and 
as  simple  division  and  proper  after-treatment  are  efficient  in  correcting 
the  deformity.' 

Posterior  Torticollis. — Besides  the  deformity  largely  associated  with 
contraction  of  the  sterno-mastoid  muscle — anterior  torticollis — another 
form  is  seen,  as  has  been  already  mentioned,  viz.,  posterior  torticollis. 
This  variety  constitutes  a  class  of  obstinate  cases.  The  only  efficacious 
treatment  is  that  of  forcible  correction  without  tenotomy,  for  the  reason 
that,  as  a  rule,  the  muscles  are  too  deep  or  extensive  to  be  tenotomized. 
The  writers  have  divided  the  outer  bands  of  the  anterior  scalenus  and 
trapezius  by  open  incision  and  can  report  the  feasibility  of  the  proced- 
ure. In  correcting  this  deformity  the  patient  should  be  thoroughly 
anaesthetized,  and  an  assistant  should  hold  the  shoulders  firmly,  while 
the  patient  should  be  so  placed  that  the  head  projects  beyond  the  end 
of  the  operating-table.  The  head  should  be  held  by  the  hands  of  the 
surgeon  and  rotated  in  all  directions,  considerable  force  being  used. 
The  danger  of  fracturing  the  spine  is  in  such  cases,  of  course,  so  slight 
as  to  be  disregarded,  and  the  deformity  can  be  overcorrected.  After 
the  operation  the  head  should  be  fixed,  the  after-treatment  resembling 
that  of  the  ordinary  torticollis. 

Spasmodic  Torticollis. — Great  difficulty  is  met  in  the  treatment  of 
spasmodic  torticollis  as  compared  to  the  congenital  torticollis,  from  the 
fact  that  the  constitutional  nature  of  the  affection  (due  to  impaired 
nervous  condition)  is  an  important  factor  to  be  considered.  The  affec- 
tion may  be  considered  a  localized  chorea  or  a  disturbance  of  the  proper 
muscular  balance  of  the  muscles  holding  the  head.  Of  the  constitu- 
'  Zeitsch.  f.  orth.  Chir.,  xi.,  3,  417. 


404  ORTHOPEDIC  SURGERY. 

tional  treatment  nothing  need  be  said,  further  than  that  the  success  of 
treatment  will  depend  upon  the  removal  of  the  patient  from  all  depress- 
ing influences,  one  of  which  is  the  distress  caused  by  the  unequal  musl 
cular  action  sometimes  accompanied  by  severe  pain.  The  surgical 
treatment  consists  of  measures  of  fixation,  muscular  rest,  muscular 
development,  and  operative  measures.  In  many  instances  the  irregular 
action  of  certain  muscles  is  due  to  their  fatigue  from  overstrain.  The 
affection  may  be  considered  a  muscle  revolt. 

Treatment  by  Rest  and  Fixation. — Treatment  by  absolute  rest 
of  all  muscles  sustaining  the  weight  of  the  head  is  indicated.  This 
can  be  furnished  by  placing  the  patient  in  a  recumbent  position  without 
pillows  and  fixing  the  head  by  sand  bags  applied  at  each  side  of  the 
head.  A  plaster  bandage  can  be  applied  or  a  moulded  leather  substi- 
tute holding  the  head,  shoulders,  and  trunk  firmly,  relieving  the  mus- 
cles from  any  weight-bearing  strain.^  With  this  the  patient  is  relieved 
of  the  restraint  of  recumbency.  Local  applications  can  be  made  to  the 
muscles  with  electricity  and  massage. 

Treatment  by  Muscular  Training. — Great  benefit  may  follow 
carefully  directed  and  graded  exercises. 

Treatment  by  Operative  Measures. — The  tedious  nature  of  con- 
servative treatment  suggests  the  employment  of  operative  measures. 
The  restoration  of  muscular  balance  by  myotomy,  fasciotomy,  and  the 
incident  temporary  muscular  rest  is  observed  in  the  surgical  treatment 
of  muscular  spasm  in  spastic  paralysis,  and  the  same  principles  can  be 
applied  in  spasmodic  torticollis.  The  muscles  involved  are  not  onl}'  the 
sterno-cleido-mastoid,  but  the  various  muscles  in  the  back  of  the  neck. 
Stretching,  division,  and  excision  of  portions  of  the  nerves  supplying 
these  muscles  have  been  employed.  Of  these  procedures  the  latter 
(viz.,  extirpation  of  the  nerves)  has  been  followed  with  the  best  result. 
As  this  involves  a  somewhat  free  dissection  of  the  tissues,  it  has  been 
suggested  that  the  benefit  following  the  procedure  is  due  more  to  the 
dissection  and  freeing  of  the  contracted  tissue  than  to  the  paralysis. 
Kocher  advises  myotomy  and  fasciotomy  alone  rather  than  nerve  resec- 
tion. Richardson  and  \\'alton,  however,  report  good  results  following 
the  latter  procedure. 

The  nerves  to  be  divided  are  the  spinal  accessory  from  the  sterno- 
mastoid,  and  a  secondary  operation  on  the  nerve  roots  of  the  deep  pos- 
terior cervical  plexus. 

Spinal  Accessory  Nerve. — This  nerve  is  divided  and  excised  for 
spasmodic  wry -neck.  It  may  be  reached  anterior  to  the  sterno-cleido- 
mastoid,  an  incision  being  made  along  the  anterior  body  of  the  muscle, 
passing  two  inches  downward  from  the  lobe  of  the  ear.     The  muscle  is 

'H.  J.  Hall:  Orth.  Trans.,  vol.  xi..  p.  233. — Boston  Med.  and  Surg.  Journ., 
March  9th.  1S99.  p.  236 


TORTICOLLIS.  405 

turned  to  the  outside  and  the  nerve  can  be  found  a  httle  above  the  level 
of  the  hyoid  bone.  If  it  be  desirable  to  reach  the  nerve,  as  is  possi- 
ble, from  the  sterno-cleido-mastoid,  the  incision  is  made  along  the  outer 
border  of  the  muscle,  the  centre  of  the  incision  being  the  centre  of  the 
muscle.     The  nerve  will  be  found  a  little  above  this  point. 

Division  of  the  Nerves  in  tJie  Deep  Posterior  Cervical  Plexus. — Keen 
divides  the  posterior  branches  of  the  first,  second,  and  third  cervical 
nerves  in  spasmodic  torticollis,  which  has  been  unrelieved  by  the  in- 
cision of  the  spinal  accessory.  A  transverse  incision  is  made  half  an 
inch  below  the  level  of  the  lobule  of  the  ear.  The  trapezius  muscle  is 
divided  in  the  same  line.  The  muscle  is  then  dissected  up  and  the 
great  occipital  nerve  is  found.  The  complexus  is  then  divided,  and  the 
great  occipital  nerve  is  followed  until  its  origin  from  the  posterior  division 
is  reached.  The  suboccipital  or  first  cervical  nerve  is  excised.  It  lies  in 
the  triangle  close  to  the  occiput  formed  by  the  two  oblique  muscles  and 
the  posterior  straight  muscle.  The  exterior  branch  of  the  posterior 
division  of  the  cervical  nerve  is  found  lower  down,  and  should  be  divided 
close  to  the  bifurcation  of  the  main  nerve. 

The  anterior  branches  of  the  cervical  plexus  may  be  reached  by 
means  of  an  incision  along  the  posterior  border  of  the  sterno-cleido- 
mastoid  muscle. 

Even  after  operative  intervention  careful  after-treatment  by  muscle 
training  is  necessary  to  obtain  permanent  cure. 

In  the  absence  of  complete  statistics  it  is  impossible  to  state  the 
absolute  relative  value  of  the  different  methods  of  treatment.  The 
treatment  in  obstinate  cases  needs  to  be  thorough.  On  the  failure  of 
non-operative  treatment,  thoroughly  and  persistently  applied,  operative 
measures  are  to  be  employed.  Reasoning  from  analogy,  sections  of 
contracted  muscular  tissue  are  as  valuable  as  nerve  excision. 


CHAPTER    XIV. 
ANTERIOR   POLIOMYELITIS. 

Definition.  — Etiology-. — Pathology. — Symptoms. — Diagnosi.s. — Differential   diag- 
nosis.— Prognosis. — Treatment. 

Anterior  poliomyelitis  or  infantile  spinal  paralysis  is  an  affection 
which  attacks  chiefly  children.  It  comes  on  with  a  sudden  onset  and 
■  deprives  certain  muscles  and  often  an  entire  limb  of  muscular  power, 
and  the  parts  affected  undergo  rapid  atrophy.  The  paralysis  is  a  purely 
motor  one. 

The  pathological  name  of  the  affection  is  acute  anterior  poliomye- 
litis, and  other  common  names  are:  Infantile  paralysis,  essential  paral- 
ysis of  children,  acute  atrophic  spinal  paralysis,  "teething  palsy"  or 
dental  paralysis.  Regressive  paral3'sis  (Barlow),  myelitis  of  the  anterior 
horns  (Seguin),  myogenic  paralysis  (Bouchut).  German:  Kinderlah- 
mung,  spinale  Kinderlahmung,  essentielle  Kinderlahmung.  French : 
Paralysie  spinale,  paralysie  infantile,  paral}'sie  des  petits  enfants,  para- 
lysie  essentielle  de  I'enfance,  tephromyelite  anterieure  aigue  (Charcot), 
etc. 

The  disease  was  first  mentioned  by  Underwood  '  in  1784,  but  it  was 
not  then  separated  clearly  from  the  other  kinds  of  paralysis  affecting 
children,  and  it  remained  for  Heine  to  give  the  first  accurate  account 
of  the  disease  in  1840. 

ETIOLOGY. 

Little  is  known  of  the  causation  of  infantile  paralysis."  The  disease 
is  usually  limited  to  the  time  of  the  first  dentition  in  children.  In 
12,694  cases  of  orthopedic  affections  in  children  under  twelve  seen  at 
the  Children's  Hospital,  Boston,  there  were  987  cases  of  anterior  polio- 
myelitis. In  599  cases  (Seeligmuller,  Galbraith,  Sinkler,  Gowers,  and 
Starr)  472  occurred  before  the  fourth  year,  118  in  the  first,  214  in  the 
second,  140  in  the  third,  and  52  in  the  fourth.  It  has  been  reported 
as  occurring"  in  a  baby  four  weeks  old.'     The  disease  has  been  seen  as 

'  "  Treatise  on  the  Diseases  of  Children."  London,  7th  ed..  1S26.  p.  251. 

'-  Duchenne  lils  :  Arch.  gen.  de  ]\Ied..  tome  ii.,  1864. — Seeligmiiller :  Gerhardt's 
"  Handbuch  der  Kinderkrankheiten."  v.,  iSSi.  p.  i. — Wharton  Sinkler:  Keating's 
"Encyclopedia."  p.  683. 

^  Schultze  :  "  Lehrb.  der  Xervenkrankheiten."  Stuttgart.  1898.  p.  223. 

406 


ANTERIOR  POLIOMYELITIS.  407 

early  in  life  as  the  twelfth  day  in  a  case  of  Duchenne's,  and  adults  are 
not  exempt  from  a  similar  affection. 

Exposure  to  severe  heat  and  sunstroke  are  mentioned  as  occasional 
causes  of  the  attack  of  paralysis.  Most  cases  occur  during  warm 
weather.  Twenty-seven  of  Barlow's  53  cases  occurred  during  July  and 
August,  and  Sinkler  found  that  in  213  out  of  270  cases  the  disease  oc- 
curred from  May  to  September  inclusive. 

An  acute  feverish  attack,  like  indigestion,  is  often  assigned  as  the 
cause,  but  inasmuch  as  it  may  be  the  chief  symptom  of  the  onset,  no 
weight  can  be  attached  to  it. 

Certain  other  cases  seem  to  come  on  after  a  fall,  and  it  is  quite  pos- 
sible that  a  traumatic  hemorrhage  into  the  substance  of  the  cord  might 
occur,  causing  much  the  same  symptoms  as  anterior  poliomyelitis,  but 
such  traumatic  histories  are  rare. 

As  a  matter  of  fact,  the  disease  attacks  healthy  and  unhealthy  chil- 
dren, boys  and  girls  alike,  usually  without  any  demonstrable  cause,  com- 
ing on  in  the  midst  of  perfect  bodily  health,  and  apparently  the  affection 
has  no  dependence  upon  a  hereditary  influence.  It  is  by  far  the  com- 
monest paralysis  in  children  and  in  most  cases  develops  during  the  night 
rather  than  the  day  and  commonly  during  the  hot  months. 

Modern  opinion  rather  inclines  toward  regarding  the  affection  as 
infectious  in  origin,  although  the  infecting  organism  has  not  been  defi- 
nitely demonstrated.  Fresh  cases  have  been  investigated  as  to  the 
presence  of  a  micro-organism,  with  negative  results  for  the  most  part. 
Schultze,'  however,  in  a  case  of  what  he  considered  anterior  poliomye- 
litis of  the  arms  and  neck  in  a  boy  of  five,  did  a  lumbar  puncture  on 
the  thirteenth  day,  and  found  in  the  cerebrospinal  fluid  withdrawn  an 
organism  which  he  described  as  the  Weichselbaum-Jager  diplococ- 
cus.  The  later  history  of  the  case  was  that  of  infantile  paralysis. 
As  a  somewhat  similar  form  of  paralysis  follows  certain  cases  of 
cerebrospinal  meningitis,  this  evidence  cannot  be  accepted  as  con- 
clusive. 

The  affection  occurs  at  times  as  an  epidemic,  which  lends  force  to 
the  view  of  its  infectious  character.  Such  epidemics  have  been 
reported  from  time  to  time.'  The  earliest  was  in  1843.'  Medin '  re- 
ported 44  cases  occurring  in  Stockholm  in  the  summer  of  1887.  There 
were  three  deaths,  and  although  in  general  the  ordinary  type  of  infan- 
tile paralysis  was  followed,  a  few  aberrant  cases  were  seen.  Briegleb  ' 
reported  an  epidemic  in  1890. 

'  Miinch.  med.  Wochenschr.,  189S,  No.  38,  p.  1197. 

-Painter:  Orth.  Trans.,  vol.  xv.,  p.  414. 

^Colmer:  Am.  Jour.  Med.  Sciences,  1843. 

''Medin:  Proceedings  Tenth  Int.  Cong.,  vol.  ii.,  div.  iv. 

*  Briegleb:  Inaug.  Diss.,  Jena,  1890. 


40 8  ORTHOPEDIC  SURGERY. 

The  epidemic  reported  by  Caverly  '  in  Vermont,  around  Rutland,  in 
the  summer  of  1894,  was  very  extensive  and  very  severe.  The  epi- 
demic included  132  cases,  and  18  cases  were  fatal.  The  cerebral  tracts 
were  in  several  cases  involved.  An  epidemic  in  Australia  was  reported 
by  Alston  in  1897,  consisting  of  14  cases.^  An  epidemic  in  Cherry- 
field,  Me.,  was  reported  by  Madison  Taylor.  There  were  7  cases  with 
I  fatality.'  W.  Pasteur*  reported  in  1896  an  epidemic  occurring  in  7 
members  of  the  same  family.  A  very  careful  investigation  of  an  epi- 
demic occurring  in  North  Adams,  Mass.,  was  made  by  Brackett.^  Ten 
cases  were  seen  and  examined  which  in  general  were  of  a  more  severe 
type  than  ordinary  cases.  The  initial  fever  was  high,  the  distribution 
of  paralysis  was  on  the  whole  more  extensive.  The  sphincters  were  at 
times  involved,  and  prolonged  hypersesthesia  was  found  in  the  severer 
cases.  These  features  seem  in  general  to  characterize  the  epidemic 
cases  as  described  by  others.  At  North  Adams  all  of  the  cases  but  one 
occurred  along  the  banks  of  the  two  rivers  flowing  through  the  town ; 
no  other  common  etiological  factor  could  be  found. 

PATHOLOGY. 

The  study  of  autopsies "  in  recent  cases  of  infantile  paralysis  has 
resulted  in  the  opinion  among  recent  writers  that  the  entire  gray  mat- 
ter of  the  cord  is  the  seat  of  interstitial  inflammation  and  that  the 
changes  in  the  ganglion  cells  are  secondary'  (Sachs).  Goldscheider's 
study  would  make  it  appear  that  the  blood-vessels  are  first  affected  and 
that  from  these  the  neuroglia  is  attacked,  and  that  the  changes  in  the 
ganglion  cells  are  degenerative  and  secondary  in  them  as  well  as  in  the 
nerve  fibres.  The  cases  of  Siemerling  are  confirmatory,  and  both  sets 
lead  to  the  view  that  the  inflammation  is  interstitial  and  not  parenchy- 
matous. 

The  process  may  involve  a  few  segments  of  the  cord,  or  it  may  in- 
volve a  greater  part  of  the  cord  and  extend  to  the  medulla  and  pons. 
The  larger  ganglion  cells  of  the  anterior  horns  in  the  affected  area  dis- 
appear and  the  ones  that  remain  are  shrunken  and  the  cell  processes 
have  disappeared.  The  entire  gray  matter  of  the  affected  side  shrinks 
and  even  the  white  matter  is  smaller  than  that  of  the  other  side.     The 

'  Journ.  Am.  Med.  Assn.,  January  4th,  1S96. 

"Australian  Med.  Gaz.,  April  24th,  1897. 

^Boston  Med.  and  Surg.  Joum.,  cxxix. ,  504. 

"•  Trans.  Clin.  Soc.  of  London,  1896,  p.  143. 

^ Trans.  Am.  Orth.  Assn.,  vol.  xi.,  p.  132. 

•>  Goldscheider :  Zeit.  f.  klin.  Med.,  xxiii.,  1893,  p.  494. — Dauber:  Zeit.  f.  Ner- 
venlieilkunde,  vol.  iv. — Siemerling:  Arch.  f.  Psychiatric,  xxvi.,  267  (with  literature 
to  1894). 

■■  Von  Kahlden  :  Cent.  f.  Path.,  September  14th,  1S94  (Charcot's  view). 


ANTERIOR  POLIOMYELITIS.  409 

columns  of  Clarke  disappear  and  the   anterior  nerve   roots   become 
smaller  than  those  of  the  other  side. 

Atrophic  changes  soon  take  place  in  the  paralyzed  limb.  Some- 
times the  atrophy  affects  the  bones,  which  become  shortened  even  to 
the  extent  of  affecting  the  length  of  a  limb  by  several  inches.  At  the 
same  time  the  affected  limb  grows  comparatively  smaller  in  circumfer- 
ence than  that  of  the  opposite  side.     This  is  frequently  the  result  of 


Fig.    368. — Anterior  Poliomyelitis.    Chronic  stage;  section  through  sixth  cervical  segment ; 
diminution  of  anterior  gray  matter  and  of  entire  half  of  right  side.     (Sachs.) 

retarded  growth  rather  than  of  real  wasting,  but  both  factors  at  times 
enter  into  the  change.  In  other  instances,  even  in  severe  cases,  the 
bones  seem  but  little  affected,  while  the  atrophy  of  the  muscles  is  very 
marked. 

The  epiphyses  are  stunted,  and  the  ligaments  become  thin  and 
loose,  and  dislocations  and  distortions  of  the  joints  are  favored.  It  is 
in  the  muscles  that  the  most  notable  changes  are  found.  These  waste 
rapidly  and  become  flabby  to  the  touch,  and  microscopic  examination 
shows  a  loss  of  striation  followed  by  a  granular  degeneration  of  the 
fibres  until  little  is  left  beyond  muscle  corpuscles  and  fat  granules  con- 
tained in  sarcolemma.  This,  of  course,  is  clearly  more  than  the  atro- 
phy of  disuse.' 

That  poliomyelitis  represents  an  acute  inflammatory  condition  of  the 
anterior  gray  matter  of  the  spinal  cord  is  conceded  on  all  sides,  but  the 
question  arises  what  the  origin  of  such  inflammation  may  be.  The 
only  satisfactory  explanation  at  the  present  day  is  to  suppose  that  the 
inflammation  is  the  result  of  an  acute  infection  which  happens  to  be 
located  in  the  spinal  cord,  just  as  other  infectious  diseases  show  a 
predilection  for  other  sites  in  the  body.  The  microbic  origin  has  not 
yet  been  satisfactorily  demonstrated,  but  all  the  clinical  facts  point 
toward  this  view,  and  the  close  dependence  of  the  myelitic  process  upon 
the  distribution  of  the  blood-vessels  lends  further  color  to  this  theory." 

'  Gowers :  "Dis.  of  Nervous  System,"  vol.  i..253. — Jacob  v.  Heine:  Loc.  cit. 
^  Sachs:  "The  Nervous  Diseases  of  Children,"  New  York,  1S95. 


410  ORTHOPEDIC  SURGERY, 

SYMPTOMS. 

In  general  the  clinical  history  of  the  disease  falls  into  three  stages : 

{a)  The  onset,  to  which  stage  belong  the  acute  febrile  symptoms 
and  the  development  of  paralysis. 

(b)  The  stage  of  convalescence,  which  begins  at  the  time  of  the  full 
development  of  the  paralysis,  and  is  followed  by  a  brief  stationary 
period,  and  finally  rapid  and  then  slower  improvement  until  a  stationary 
period  is  reached. 

(<:)  The  stage  of  deformity,  in  which  wasting  of  the  affected  limb  is 
present  and  static,  paralytic,  and  contraction  deformities  have  super- 
vened. 

No  arbitrary  subdivision  of  the  classes  of  symptoms  will  be  made, 
because  in  reality  the  stages  run  into  each  other  so  gradually  that  it 
seems  unjustifiable  to  divide  them  practically. 

Infantile  paralysis  is  oftenest  ushered  in  by  a  mild  or  severe  febrile 
attack,  which  presents  no  definite  characteristics  to  distinguish  it  from 
any  ordinary  attack  of  cold  or  indigestion.  The  elevation  of  tempera- 
ture is  not  excessive,  commonly  from  ioo°  to  102°  F.,  sometimes  even 
104°.  With  this  fever  are  apt  to  be  associated  vomiting,  convulsions, 
giddiness,  or  other  cerebral  disturbance,  sometimes  even  delirium. 
Older  children  complain  of  pain  in  the  back  and  limbs.  There  is,  as  a 
rule,  no  warning  of  the  attack,  although  Seeligmiiller  has  noted  at 
times  a  disinclination  to  walk  or  stand  as  much  as  usual  for  some  days 
preceding — a  fact  quite  in  accordance  with  Lange's  theory  that  over- 
exertion of  the  muscles  has  much  to  do  with  the  production  of  the  dis- 
ease. Convulsions  may  be  present,  and  when  they  occur  they  are 
usually  followed  by  a  period  of  unconsciousness.  The  feverish  attack 
at  the  onset  may,  however,  be  very  severe,  at  times  lasting  two  or  three 
days  (or  even  weeks)  before  the  paralysis  appears.  More  commonly, 
however,  it  is  very  slight  and  scarcely  noticed.  In  certain  rare  cases, 
two  or  even  three  attacks  of  fever  are  noted,  each  followed  by  an  in- 
crease in  the  paralysis.  Pain  of  a  rheumatic  character  in  the  back  and 
limbs  is  a  common  initial  symptom.  In  certain  cases  all  feverish  and 
other  symptoms  are  absent  at  the  onset,  and  the  child  is  suddenly  dis- 
covered to  be  paralyzed  in  one  or  more  limbs.  Such  paralysis  comes  on 
oftenest  in  the  night,  but  it  has  been  observed  to  come  on  quietly  in 
the  daytime,  while  the  child  was  at  play.  In  these  cases  there  may  be 
no  succeeding  illness,  and  the  paralysis  is  the  only  symptom  through- 
out. 

Diarrhoea,  vomiting,  general  hyperaesthesia,  and  much  nervous  irri- 
tability are  other  symptoms  which  often  accompany  the  onset  of  the 
paralysis.  During  the  first  few  days  there  may  be  paralysis  of  the  blad- 
der with  retention  or  incontinence  of  urine,  but  it  disappears  after  a 


ANTERIOR   POLIOMYELITIS.  411 

few  days  or  weeks.  Pain  is  a  symptom  but  little  noted  in  infantile 
paralysis,  but  it  is  not  uncommon,  nor  does  it  indicate  of  itself  the 
presence  of  any  additional  pathological  process. 

The  paralysis  itself  very  quickly  becomes  manifest  and  reaches  its 
maximum  within  a  few  hours  of  the  attack,  or  within  a  day  or  two, 
except  in  rare  cases.  Having  reached  its  maximum  and  remained  sta- 
tionary for  a  short  time,  improvement  almost  invariably  begins.  In 
rare  cases  improvement  begins  immediately  after  the  attack  and  pro- 
ceeds to  complete  recovery.  These  are  the  cases  which  are  spoken  of 
as  "  temporary  spinal  paralysis."  The  more  common  course  is  for  the 
paralysis  to  remain  nearly  stationary  for  a  time  varying  from  two  to  six 
weeks,  and  then  to  improve,  at  first  rapidly  and  then  more  slowly,  for 
three  or  four  months.  After  six  months  have  passed,  further  sponta- 
neous improvement  is  unusual. 

Vascular  changes  become  very  marked.  The  temperature  of  the 
limb  is  much  lower  than  that  of  the  other.  The  limb  is  generally  blu- 
ish, with  a  superficial  stagnation  of  the  blood,  on  account  of  an  atrophy 
of  the  blood-vessels  and  consequent  diminution  of  their  calibre,  and 
when  the  blood  is  pressed  out  of  the  surface  capillaries  by  the  finger  it 
returns  slowly.  On  account  of  this  vascular  sluggishness  ulcers  may 
form,  which  are  slow  to  heal  and  very  painful.  The  limb  even  very 
early  loses  its  normal  appearance,  and  the  flaccid  undeveloped  look  of 
the  foot  or  hand  is  most  noticeable. 

Atrophy  of  the  affected  muscles  begins  to  be  perceptible  a  few 
weeks  after  the  onset  of  the  paralysis,  while  the  loss  of  striation  in  the 
muscular  fibres  can  be  detected  with  the  microscope  within  two  or 
three  days  of  the  attack.'  The  muscles  may  be  tender  to  the  touch 
during  the  time  that  they  are  wasting  so  fast,  especially  in  adults 
and  older  children.  Muscles  seriously  affected  are  toneless  and 
flaccid  from  the  first,  and  in  the  late  stages  of  wasting  scarcely  any 
volume  of  muscles  seems  left  when  the  limb  is  grasped  with  the 
hand. 

The  paralysis  is  a  purely  motor  one,  and  although  tingling  and  for- 
mication may  be  present,  sensation  is  very  rarely  affected.  The  reflexes 
are  abolished  in  the  affected  limb  if  the  implication  of  the  extensor 
muscles  of  the  thigh  be  enough  to  do  away  with  the  knee  jerk  of  the 
affected  side. 

Sometimes  after  an  attack  the  paralysis  may  seem  to  be  general, 
but  the  probabilities  are  that  after  improving  in  general,  the  loss  of 
power  will  eventually  be  localized  in  one  limb,  and  that  if  one  limb  orig- 
inally is  paralyzed  the  likelihood  is  ver}'  great  that  a  certain  amount  of 
power  will  be  regained,  leaving  only  certain  groups  of  muscles  perma- 
nently paralyzed. 

^H.  W.  Berg:  Wood's  "  Ref.  Handbook."  vol.  v.,  p.  504. 


412  ORTHOPEDIC  SURGERY. 

Distribution. — The  paralysis  in  its  distribution  is  monoplegic  in 
about  half  the  cases,  as  the  tables  taken  from  the  cases  of  Duchenne, 
Seeligm tiller,  Sinkler,  and  Starr  will  show: 

Both  legs, 170 

One  leg, 246 

Both  arms, 6 

One  arm,            47 

All  extremities, 47 

Arm  and  leg,  same  side, 33 

"     opposite  sides, 8 

Trunk 26 

Three  extremities, 12 

595 

The  great  preponderance  of  paralysis  of  the  lower  extremities  is  to 
be  noted,  and  the  liability  to  paralysis  increases  even  from  the  thigh  to 
the  foot,  and  when  improvement  begins  in  a  case  in  which  both  an 
upper  and  a  lower  extremity  are  paralyzed,  the  improvement  begins  first 
in  the  arm.  Commonly  certain  groups  of  muscles  are  attacked,  and 
when  adjacent  muscles  are  affected  they  seem  to  be  selected  at  random 
oftener  than  by  functional  or  anatomical  association.  In  the  leg,  the 
extensors  and  the  peronei  are  the  muscles  oftenest  affected.  The  glu- 
tei are  never  affected  alone,  but  they  commonly  share  in  any  extensive 
paralysis  of  the  leg..  In  the  arm  the  deltoid  suffers  oftener  than  any 
other  arm  muscle,  either  alone  or  in  association  with  other  muscles. 
The  "  upper-arm  type  "  of  paralysis,  which  Erb  has  described,  consists 
of  the  simultaneous  affection  of  the  deltoid,  supra-  and  infraspinatus, 
the  biceps,  and  the  supinators.  There  is  also  a  "forearm  type  "de- 
scribed by  Remak,'  in  which,  as  in  lead  paralysis,  the  extensor  muscles 
of  the  hand  are  paralyzed  while  the  supinator  longus  is  spared.  The 
serratus  magnus  is  sometimes  affected  as  well  as  the  trapezius  and  pec- 
toralis  major.  The  neck  muscles  are  very  seldom  affected  and  the  mus- 
cles supplied  by  the  cranial  nerves  only  rarely. 

The  muscles  of  the  back  may  be  paralyzed  and  the  patient  be  una- 
ble to  sit  erect,  or  lateral  curvature  may  result — a  state  of  affairs  often 
made  worse  by  allowing  the  patient  to  sit  erect  while  the  muscles  are 
still  weak.  The  diaphragm  is  occasionally  paralyzed.  In  those  rare 
cases  of  paralysis  of  the  abdominal  muscles,  the  patient  leans  back  to  a 
very  marked  degree,  missing  the  restraining  action  of  the  abdominal 
muscles.  There  are,  finally,  cases  of  universal  paralysis  in  which  death 
soon  takes  place  from  interference  with  respiration. 

The  sequelae  of  the  disease  are  few. 

^Remak:  Arch.  f.  Psych.,  Band  ix. ,  1S78-79,  p.  510. 


ANTERIOR  POLIOMYELITIS,  413 

Deformities. — The  deformities  whicli  come  on  after  infantile  paraly- 
sis are  late  events  in  the  history  of  the  disease  and  rarely  develop  until 
at  least  some  months  after  the  attack.  They  are,  as  a  rule,  progressive 
in  their  character  and  the  end  results  are  often  such  extreme  distor- 
tions that  the  affected  limb  is  useless.  The  deformities  fall  into  two 
chief  classes:  (i)  deformities  due  to  trophic  changes,  such  as  bone 
shortening,  etc. ;  (2)  deformities  due  to  muscular  paralysis. 

(i)  The  first  class  is  comparatively  unimportant;  shortening  of  the 
paralyzed  arm  or  leg  may  take  place  with  atrophy  of  the  bone  in  every 
direction,  so  that  a  liability  to  fracture  is  of  course  a  necessary  conse- 
quence. Shortening  of  the  arm  is  comparatively  unimportant  in  itself, 
but  shortening  of  the  leg  is  likely  to  induce  lateral  curvature  of  the 
spine  from  the  necessarily  tilted  position  of  the  pelvis  '  due  to  the  un- 
equal length  of  the  legs. 

(2)  The  deformities  of  the  second  class,  which  are  the  result  of 
muscular  paralysis,  are  manifold  and  form  the  great  bulk  of  the  cases 
of  deformity  in  anterior  poliomyelitis.  As  a  rule  they  do  not  appear 
earlier  than  two  or  three  months  after  the  onset  and  more  commonly 
not  for  many  months. 

For  clinical  consideration  they  fall  into  two  groups:  deformities 
caused  by  contraction,  and  deformities  due  to  laxity  of  the  muscles  and 
ligaments.  Volkmann,  on  the  ground  of  Hiiter's  investigations,  ex- 
plained nearly  all  the  deformities  on  mechanical  grounds,  urging  that 
the  deformities  were  developed  partly  by  reason  of  the  weight  of  the 
limbs  concerned  and  the  position  which  they  assumed  when  at  rest,  and 
partly  because  of  the  muscular  insufficiency  of  the  affected  limbs  which 
allowed  the  articular  surfaces  to  be  subjected  to  an  excessive  pressure 
when  brought  into  use,  which  had  the  effect  of  gradually  pressing  them 
into  abnormal  position.  The  earlier  idea  had  been,  however,  that  they 
were  brought  about  by  the  unopposed  action  of  the  muscles  which  were 
not  affected.  Probably  both  factors  are  active  in  the  causation  of  de- 
formity. 

A  word  should  be  said  in  regard  to  the  reason  of  the  more  severe 
affection  of  the  anterior  leg  and  thigh  muscles  than  of  the  posterior 
muscles  in  nearly  all  cases.  The  theory  has  been  advanced  that,  after 
a  paralysis  of  the  leg,  the  limb  lies  flaccid  and  nearly  powerless,  the 
toes  drop,  and,  if  the  sitting  posture  is  assumed,  the  knees  flex  and  the 
legs  hang  heavily  down.  As  a  result  of  this,  the  anterior  muscles  are 
always  pulled  upon  and  slightly  stretched,  while  the  posterior  ones  are 
lax.  If  all  the  muscles  are  equally  affected,  this  very  factor  may  be 
enough  to  make  a  great  difference  in  the  ultimate  usefulness  of  the  two 
groups.     Stretched  muscles  are  notoriously  at  a  disadvantage,  so  far  as 

'Bradford:  "Etiology  of  Lateral  Curvature,"  Boston  Med.  and  Surg  Jour, 
1886,  cxiv. 


414 


ORTHOPEDIC  SURGERY. 


recovery  goes,  in  any  diseased  condition,  and  muscles  at  rest  are  much 
more  favorably  situated.  So  that  this  very  point  may  determine  in  a 
measure  the  relative  amount  of  recovery  in  the  two  groups. 

Moreover,  muscular  contraction  and  consequent    deformity  occur 
only  in  cases  in  which  a  muscle  has  been  allowed  to  remain  for  a  long 
time  in  a  shortened  or  stretched  condition.     For  this  reason  it  is  highly 
important  to  support  and  restrain 
the  affected  limb  in  a  normal  po- 
sition (the  foot  at  a  right  angle 
to  the  leg,  etc.). 

The  common  deformities  from 
infantile  paralysis  which  come  to 
the  orthopedic  surgeon  for  treat- 


FlG.  369.— Kyphosis  in  Advanced  Paralysis 
of  the  Back  Muscles. 


Fig. 


370.  — Infantile  Paralj'sis.    Contract- 
ures of  right  leg.     (.Weigel.) 


ment  are  those  of  the  lower  extremity.  Considered  in  detail,  it  is  best 
to  begin  with  deformities  at  the  hip-joint  and  then  to  pass  on  to  the 
consideration  of  knee-joint  deformities  and  distortions  of  the  foot. 

Deformities  of  the  Leg. — Paralysis  may  be  complete  and  a  flail-like 
leg  be  the  result,  with  wasted  muscles  and  loose,  distorted  joints,  inca- 
pable of  motion  or  bearing  weight.  Such  a  limb  is  spoken  of  as  "  jambe 
de  Polichinelle." 

But  more  commonly  the  paralysis  is  partial  rather  than  complete. 


ANTERIOR  POLIOMYELITIS. 


415 


The  muscles  of  the  thigh  commonly  affected  are  the  internal  and  ante- 
rior groups.  This  constitutes  a  serious  combination  and  renders  walk- 
ing difficult ;  not  only  is  the  leg  abducted  with  a  tendency  to  eversion, 
but  the  extensor  thigh  muscles  cannot  hold  the  knee  rigid  as  is  neces- 
sary in  walking,  the  leg  giving  way  whenever  weight  is  put  upon  it. 
The  glutei  are  generally  implicated  in  this  paralysis,  and  the  contraction 


Fig.  371. — Paralj'sis  of  the  Left  Leg-,  with  Talipes  Equinus  and  Involvement  of  the  Internal 
Rotators  and  Abductors  of  the  Leg,  Resulting  in  a  Position  of  Abduction  and  Eversion. 


which  is  likely  to  result  from  this  paralysis  is  flexion  of  the  thigh  alone 
or  with  abduction  of  the  leg,  a  condition  always  associated  with  flexion 
of  the  knee  and  talipes  equino-varus. 

Flexion  deformity  at  the  hip  produces  in  time  a  most  marked  lordo- 
sis in  the  back.  When  the  patient  stands  with  the  leg  dangling,  the 
weight  of  it  drags  upon  the  pelvis  and  rotates  it  on  a  transverse  axis,  a 
compensation  which  makes  it  possible  for  the  leg  to  hang  as  nearly  as 
possible  perpendicularly.     This  deformity  is  marked  and  troublesome. 


41 6  ORTHOPEDIC  SURGERY. 

At  the  knee,  contraction  in  the  flexed  position  (with  often  a  ten- 
dency to  subkixation  of  the  tibia  backward)  is  found,  and  in  the  more 
severe  cases  decided  knock-knee.  At  other  times  when  laxity  rather 
than  contraction  predominates,  hyperextension  of  the  knee  is  observed 
and  sometimes  lateral  mobility  also  exists.     In  severe  cases  of  this  type 


Fig.  372.  — Severe  Double  Paralysis  with  ^larked  Knock-knee  and  Distortion  of  Feet.    This 
patient  was  unable  to  walk. 

in  which  the  deformity  has  been  rectified  by  mechanical  or  operative 
means,  the  tibia  lies  in  a  plane  decidedly  posterior  to  that  of  the  femur. 
The  same  may  be  said  of  the  knock-knee  which  results  from  the  greater 
prominence  of  the  internal  condyle  of  the  femur.  The  flexion  may 
have  been  overcome,  but  still  a  decided  degree  of  knock-knee  may  re- 
main in  the  corrected  leg. 

Hyperextension  of  the  knee  may  also  increase  to  a  very  marked 
degree  and  is  commonly  associated  with  talipes  valgus.  This  hyperex- 
tension results  in  cases  in  which  the  anterior  muscles  are  weak  and  fail 
to  hold  the  knee  extended  when  walking  is  attempted.  In  these  cases 
the  patient  throws  the  weight  of  the  body  upon  the  fully  extended  knee 


ANTERIOR  POLIOMYELITIS. 


417 


and  the  strain  falls  upon  the  ligaments  rather  than  on  the  muscles. 
The  posterior  ligaments  yield  in  time  to  this  repeated  weight  and  the 
patient  obtains  for  a  time  a  better  bearing.  The  same  deformity  is 
favored  by  a  tendency  which  these  patients  have  to  lean  with  the  hand 
upon  the  knee  when  rising  from  a  chair. 

There  is  a  tendency  to  outward  rotation  of  the  tibia  upon  the  femur 
in  cases  of  long-standing  paralysis  of  the  leg.  In  this  case  the  eversion 
of  the  foot  in  walking  is  a  troublesome  complication. 

Inasmuch  as  paralyses  of  the  anterior  tibial  muscles  and  the  peronei 
are  the  most  frequent,'  the  deformities  that  one  sees  oftenest  are  talipes 


Fig.  373.— Hyperextension  of  the  Left  Knee  due  to  Paralysis  of  the  Limb.    Varus  deformity 

of  the  right  foot. 

equino-varus,  or,  if  the  peronei  are  intact,  talipes  equinus.  Pure  talipes 
varus  from  this  cause  is  not  common. 

It  will  be  seen  that  hyperextension  of  the  knee  is  favored  in  cases  in 
which  talipes  equinus  exists,  as  by  that  means  alone  the  foot  can  be 
placed  flat  on  the  ground. 

Talipes  calcaneo-valgus  and  pure  flat-foot  are  favored  by  lax  liga- 
ments, and  the  latter  may  be  a  progressive  deformity,  which  increases 
until  a  stage  is  reached  in  which  the  inner  malleolus  almost  touches  the 
ground  and  the  foot  can  be  flexed  until  the  dorsum  touches  the  skin 

'  Ross:  "  Dis.  of  Nerv.  Syst. ,"  William  Wood  &  Co.,  187S,  p.  942. 
27 


4i8 


ORTHOPEDIC  SURGERY. 


over  the  tibia.     The  bearing  of  body-weight  on  a  foot,  the  Hgaments 
and  muscles  of  which  are  weak,  tends  to  produce  flat-foot. 

Pure  talipes  calcaneus  seems  to  be  the  result  of  the  paralysis  of  the 
posterior  calf  muscles  combined  with  the  action  of  gravity  and  super- 
incumbent weight.  What  is 
known  as  pes  cavus  is  more 
common  than  pure  talipes  cal- 
caneus. 

The  order  of  frequency  of 
the  different  forms  of  deform- 
ity from  anterior  poliom}-elitis 
is  as  follows :  (i)  talipes  equino- 
varus;  (2)  calcaneo-valgus ;  (3) 
equinus;  (4)  calcaneus  or  pes 
cavus. 

Deformities  of  the  arms  are 
not  common  as  the  result  of 
infantile  paralysis.  The  least 
infrequent  of  these  results  from 
the  paralysis  of  the  deltoid.  In 
addition  to  the  inabilit}'  to  raise 
the  arm  from  the  side,  there 
are  present  a  flattening  of  the 
shoulder  and  a  prominence  of 
the  acromion  process,  and  the 
shoulder  presents  an  angular 
rather  than  a  rounded  outline. 
The  ligaments  are  loosened,  and 
the  arm  hangs  loosely,  so  that 
in  some  cases  a  wide  gap  may 
be  observed  between  the  acro- 
mion and  the  humerus. 

An}-  distortion  of  the  arm 
and  hand  further  than  the 
flaccid  condition  resulting  from  the  paralysis  is  quite  rare.  If  con- 
traction does  occur,  it  follows  the  type  to  be  seen  in  adult  hemiplegia : 
flexion  of  the  elbow,  hand,  and  fingers.  The  commonest  paralysis  of 
the  hand  is  one  affecting  the  adductor  muscles  of  the  thumb,  as  a  re- 
sult of  which  the  thumb  is  drawn  back  to  a  level  with  the  other  fingers 
and  the  power  to  oppose  it  to  the  other  fingers  in  grasping  is  thus  lost. 
Infantile  paralysis  of  the  sterno-mastoid  muscle  is  recognized  as  an 
occasional  cause  of  wry-neck.  Paralysis  of  the  intercostal  muscles 
rarely  causes  deformity,  but  Gowers  saw  a  case  in  which  a  permanent 
depression  in  one  side  of  the  thorax  resulted  from  such  a  paralysis. 


Fig.  374. — Paralysis  of  Both  Legs,  Severest  in 
Right.  Knock-knee  and  flail-like  legs.  This 
patient  was  unable  to  walk  without  crutches. 


ANTERIOR   POLIOMYELITIS. 


419 


Paralysis  of  the  erector  spinas  muscles  results  in  a  permanent  arching- 
of  the  spine  and  inability  to  sit  erect.  Paralysis  of  the  abdominal  mus- 
cles causes  lordosis. 

Lateral  curvature  of  the  spine  results  from  infantile  paralysis  in  one 
of  three  ways : 

(i)  From  the  inequality  in  the  length  of  the  legs  (due  to  paralysis 
of  one  leg),  causing  tilting  of  the  pelvis.  (2)  From  the  unilateral  paral- 
ysis of  the  muscles  directly  controlling  the  vertebral  column,  which 
might  be  either  a  paralysis  of  the  intrinsic  spinal  muscles  or  of  the 
erector  spinae  group  on  one  side.  (3)  From  faulty  spinal  attitudes  as- 
sumed in  consequence  of  some  paralysis  elsewhere,  as  in  paralysis  of 
one  arm,  or  of  the  serratus  magnus,  or  even  of  the  sterno-mastoid. 
These  cases  have  been  more  particularly  considered  under  the  head  of 
lateral  curvature. 

Dislocations  from  Infantile  Paralysis. — Dislocation,  complete  or 
partial,  belongs  to  the  more  uncommon  of  the  complications  of  infantile 
paralysis  and  characterizes  severe  cases. 

Dislocation  of  the  hip  is  the  one  most  commonly  met  and  it  takes 
place  either  spontaneously  or  in  consequence  of  weight  being  borne 


Fig.  375.— Paralysis  of  the  Back  Muscles,  Causing-  Saddle- back  Deformity. 

upon  a  limb  which  is  improperly  supported  by  its  ligaments.  It  occurs 
chiefly  in  cases  in  which  the  paralysis  is  severe  and  of  long  standing,  and 
it  may  disable  the  leg  on  account  of  the  laxity  with  which  the  femur 
articulates  with  the  pelvis.  A  shortening  of  one  or  two  inches  may  be 
present,  as  the  dislocation  is  generally  on  to  the  dorsum  of  the  ilium ;, 


420 


ORTHOPEDIC  SURGERY. 


but  sometimes  it  takes  the  form  of  a  laxity  of  the  joint  in  all  directions, 
so  that  the  head  may  be  thrown  into  any  position  by  manipulation  of 
the  shaft.  Most  dislocations  of  the  hip  are  inconvenient  chiefly  be- 
cause of  the  shortening  and  insecurity  which  follow  the  displacement  of 
the  head  of  the  bone.  But  the  head 
of  the  bone  in  a  year  or  two  becomes 
often  quite  firmly  fixed  in  its  new 
position,    and    such    legs    are    some- 


PiG.  376. — Paral\-sis  of  the  Left  Arm  Muscles,  Del- 
toid and  Serratus  Magnus. 


Fig.  377.— Moderate  Degree  of  Talipes 
Valgus,  Right  Foot. 


times  nearl)'  as  serviceable  as  they  were  before.  Dislocation  may, 
however,  occur  before  any  weight  is  borne  upon  the  affected  limb,  by 
the  spontaneous  action  of  the  muscles,  as  in  a  patient  eighteen  months 
old,  in  the  experience  of  one  of  the  writers,  in  which  dislocation  of  one 
h^p  took  place  at  the  age  of  three  months.  In  this  case  the  dislocation 
was  reduced  under  an  anaesthetic,  and  by  the  application  of  a  plaster- 
•of-Paris  bandage  the  head  of  the  femur  was  permanently  retained  in  the 
acetabulum.  These  dislocations  are  rarely  attended  by  much  pain  and 
are  often  overlooked  by  the  parents. 

Laxity  of  the  knee-joint,  so  that  the  joint  surfaces  slip  by  each  other 
in  the  motions  of  the  joint,  is  a  less  common  affection,  but  is  sometimes 
seen.     In  these  cases  the  joint  is  subluxated  at  each  step. 


ANTERIOR  POLIOMYELITIS. 


42  1 


The  subluxation  of  the  tibia  in  severe  cases  of  knee  flexion  and  the 
dislocation  of  the  shoulder  after  paralysis  of  the  deltoid  muscle  have 
been  already  mentioned. 

DIAGNOSIS. 

In  typical  cases  the  diagnosis  of  infantile  paralysis  is  not  difficult. 
But  in  other  than  typical  cases  the  recognition  of  the  disease  may  be 
extremely  difficult,  and  it  is  never  easy  to  establish  a  positive  diagnosis 
in  the  initial  stage.  At  that  time  the  occurrence  of  localized  pain  may 
be  a  misleading  symptom,  and  sensitiveness  of  the  affected  limbs  may 
suggest  rheumatism.  The  occurrence  of  convulsions  and  unconscious- 
ness may  divert  the  attention  to  the  brain,  and  all  sorts  of  side  issues 
may  be  suggested  by  the  manifold  symptoms  of  the  onset  of  the  disease. 
The  affection  is  often  wrongly  classed  as  cerebrospinal  meningitis  at 
the  earliest  stage,  as  the  head  is  sometimes  drawn  backward  in  severe 
cases. 

The  diagnostic  points  upon  which  the  practitioner  must  rely  are  the 
sudden  onset,  a  motor  paralysis,  rapid  muscular  wasting,  the  distribu- 


FlG.  378.— Talipes  Varus,  Right  Foot. 

tion  of  the  paralysis  (mostly  monoplegic  and  very  rarely  hemiplegic), 
and  the  loss  of  the  tendon  refiex.  Diagnosis  by  the  determination  of 
the  electrical  reaction  of  the  muscles  requires  especial  training  and  skill, 
although  it  is  distinctive  and  the  most  reliable  test  at  our  command. 

Electrical  Condition  of  the  Muscles. — The  electrical  reactions  in 
infantile  paralysis  are  clearly  marked  and  characteristic  when  they  can 


422 


ORTHOPEDIC  SURGERY. 


be  obtained.  Faradic  irritability  of  the  affected  muscles  and  nerves 
begins  to  diminish  within  a  day  or  two  of  the  onset  of  the  paralysis,  and 
in  muscles  severely  affected  the  electric  irritability  disappears  entirely ; 
in  the  muscles  less  seriously  involved  it  is  merely  diminished.  This 
constitutes  a  valuable  symptom  in  prognosis,  as  in  muscles  which  are 
completel}'  parah-zed  faradic  irritability  is  permanently  lost  by  tJie  sec- 
ond week.  But  even  in  later  years  it  may  be  possible  to  find  in  such 
muscles  a  trace  of  irritability  to  the  faradic  current  by  thrusting  a  hy- 
podermic needle  into  the  muscular  substance  and  transmitting  the  cur- 


PlG.  379.  —  Flexion  Deformity  of 
the  Hip,  Knee,  and  Ankle,  due 
to  Contractions. 


Fig.  380.— Dislocation  of  Hip,  the  Result  of  In- 
fantile Paralysis.  In  this  position  the  head 
of  the  femur  (left)  is  in  place,  but  with  ab- 
duction it  slips  out  again. 


rent  through  that.  But  the  change  in  reaction  to  the  galvanic  current 
is  even  more  important.  Normally  when  this  current  is  passed  through 
ner\'e  and  muscle,  a  quick,  sharp  muscular  contraction  takes  place  at  the 
opening  and  closing  of  the  current,  and    the  muscular    contraction 


ANTERIOR  POLIOMYELITIS, 


423 


should  be  greater  at  the  closing  of  the  negative  pole  than  when  the 
positive  pole  is  closed.  The  cathodal  closing  contraction  should  be 
normally  greater  than  the  anodal  closing  contraction.  When  nerves 
and  muscles  affected  by  anterior  poliomyelitis  are  examined,  not  only  a 


Fig.  381. — Same  Case  as  Shown  in  Fig. 
380,  with  Hip  Dislocated. 


Fig.  382. -Old  Paralysis  of  Left   Leg-  with 
Slight  Knock-knee  and  Talipes  Varus. 


slow  wave-like  response  to  electricity  instead  of  a  sharp  quick  jerk  is 
found,  but  the  electrical  formula  is  reversed  and  tJie  closure  of  tJie  posi- 
tive pole  gives  the  greater  contraction.  In  general  a  much  stronger  gal- 
vanic current  is  needed  to  produce  a  contraction  in  these  paralyzed 
muscles  than  in  normal  ones.  These  qualitative  and  quantitative 
changes  in  reaction  to  the  galvanic  current  constitute  what  is  known  as 
the  "reaction  of  degeneration,"  and  this  affords  the  most  definite 
ground  for  the  diagnosis  of  infantile  paralysis.  But  such  an  examina- 
tion to  be  of  any  value  requires  practice  and  special  skill  in  the  use  of 
electricity.  In  young  children  the  examination  often  yields  no  results 
even  to  a  specialist  in  nervous  diseases  on  account  of  the  child's  con- 
stant activity,  and  although  it  is  the  most  definite  means  of  diagnosis  that 
we  possess  in  obscure  cases,  its  use  is  attended  with  many  difficulties. 


424 


ORTHOPEDIC  SURGERY. 


The  only  affection  which  may  not  be  distinguished  by  electrical  ex- 
amination from  anterior  poliomyelitis  is  peripheral  paralysis  caused  by 
interruption  in  the  course  of  some  nerve. 

DIFFERENTIAL    DIAGNOSIS. 

The  leading  points  which  are  to  be  depended  upon  in  the  differen- 
tial diagnosis  are  these :  Infantile  paralysis  is  purely  a  motor  affection 
and  sensation  is  never  permanently  impaired.  The  reflexes  are  gener- 
ally diminished  or  lost.  Wasting  is  rapid  and  extreme  and  the  leg  is 
cold  and  blue  in  severe  cases.  The  "  reaction  of  degeneration  "  is  pres- 
ent in  electrical  examination. 

Cerebral  paralysis  generally  begins  with  a  sudden  onset,  and  often 
convulsions  are  present  and  the  child  is  found  to  have  lost  the  use  of 
one  side  of  the  body.  It  differs  from  infantile  paralysis  in  these  points : 
its  distribution  is  hemiplegic  and  facial  paralysis  is  common,  the  tendon 
reflexes  are  increased  from  first  to  last,  faradic  excitability  is  not  lost, 
and  the  galvanic  formula  is  normal ;  later  the  intelligence  is  generally 
affected  and  atrophy  is  neither  so  marked  nor  so  rapid  as  in  infantile 
spinal  paralysis,  but  similar  contractions  of  the  joints  of  the  affected 
limb  come  on.  These  contractions  are,  however,  often  spastic  in  char- 
acter. Allusion  must  be  made  to  the  importance  of  electricity  in  mak- 
ing a  differential  diagnosis,  which  is  often  attended  with  much  difficulty. 
A  hemiplegic  distribution  of  infantile  spinal  paralysis  is  rare,  but  cases 
have  been  reported  in  which  the  facial  nerve  was  involved.' 

Table  of    the    Differextial    Diagnosis    of    Infantile   Paralysis    and 

Cerebral  Paralysis. 


Age. 

Onset. 

Distribution  of 
paralysis. 

Rei^exes. 
Electrical  reaction. 


Mental 
ment. 


impair- 


Infantile  Spinal  Paralysis. 

Sharply  limited  to  children  in 
first  dentition. 

Sudden,  but  severe  convul- 
sions not  often  present. 

Oftenest  monoplegia  or  para- 
plegia ;  rarely  involves  fa- 
cial nerve. 

Lost  generally. 

Faradism,  diminished  or  lost. 

Galvanism,  formula  reversed 
(reaction  of  degeneration). 

Absent. 

Spastic  condition  absent. 


Cerebral  Paralysis  (HemipleT^a). 

Not  sharply  limited  to  young 
children. 

Sudden,  and  severe  convul- 
sions generally  present. 

Hemiplegia ;  generally  involv- 
ing facial  muscles  on  one 
side. 

Increased. 

Faradism,  normal. 

Galvanism,  normal. 

Likely  to  come  on. 

Spastic  condition  of  one  or 
both  lears  often  follows. 


Progressive  muscular  atrophy  in  childhood  is  a  very  rare  affection, 
but  it  has  been  observed,  sometimes  beginning  in  the  legs.     Its  onset 


Henoch:  Loc.  cii.,  p.  203. — Barlow:    Loc.  cit.,  p.  76.— Seeligmiiller. 


ANTERIOR  POLIOMYELITIS.  4^5 

is  gradual,  and  the  faradic  excitability  remains  so  long  as  there  is  any 
muscular  substance  left  and  the  galvanic  formula  remains  normal.  The 
reflexes  are  not  lost  until  all  muscular  substance  has  gone. 

Acute  transverse  myelitis  of  the  dorsal  region  causes  paralysis  of 
the  legs  when  it  occurs,  but  unless  the  lumbar  enlargement  is  involved 
there  is  no  loss  of  electrical  irritability.  Reflex  action  after  a  day  or 
two  is  much  increased  and  ankle  clonus  can  be  obtained.  There  is 
generally  paralysis  of  sensation,  and  bed-sores  develop  with  much  ra- 
pidity, while  any  wasting  is  very  gradual.  There  is  no  change  in  the 
electrical  formula. 

A  paralysis  much  like  that  in  anterior  poliomyelitis  has  been  de- 
scribed by  Bullard  following  cerebrospinal  meningitis }  In  such  cases 
pain  and  tenderness  of  muscles  persist  longer  than  in  infantile  paraly- 
sis. There  is  a  tendency  to  spastic  contraction  in  the  early  stages, 
which  becomes  less  later.  The  knee-jerks  on  the  whole  are  less 
affected  than  in  infantile  paralysis ;  they  may,  however,  be  absent  en- 
tirely. 

Diphtheritic  paralysis  may  offer  serious  difficulty  in  diagnosis,  be- 
cause anterior  poliomyelitis  may  occur  in  the  course  of  a  diphtheritic 
attack  as  in  any  other  infectious  disease.  The  paralysis  of  diphtheria 
affects  oftenest  the  muscles  of  the  palate  and  fauces,  the  electrical  reac- 
tions remain  normal,  and  severe  atrophy  is  not  present. 

Pseiido-hypertrophic  paralysis  in  its  early  stages  is  not  likely  to  be 
confused  with  infantile  paralysis,  for  it  is  generally  characterized  by 
much  increase  in  the  size  of  the  muscles,  which  is  extensively  distrib- 
uted and  comes  on  very  gradually  and  is  not  accompanied  by  any 
marked  electrical  changes.  Late  in  the  affection  marked  muscular 
atrophy  occurs,  but  it  is  generalized  and  the  history  would  clearly 
differentiate  the  condition  from  anterior  poliomyelitis. 

Paralysis  may  result  from  lesions  of  a  peripJieral  neive,  as  in  instru- 
mental delivery  at  childbirth,  from  tight  bandaging,  etc.  But  its  dis- 
tribution is  limited  to  a  single  nerve  or  group  of  nerves,  and  it  is  char- 
acterized by  a  concomitant  affection  of  sensibility.  The  electrical 
reaction  would  be  the  same  as  in  infantile  paralysis. 

The  so-called  rhacJiitic  paralysis  might  offer  some  difficulty  of  diag- 
nosis. But  it  occurs  in  the  acute  stage  of  rickets  and  is  not  a  paraly- 
sis so  much  as  a  disinclination  to  use  weak  and  tender  limbs.  It  is 
accompanied  by  general  tenderness  and  to  a  certain  extent  by  the  diag- 
nostic signs  of  rickets,  the  reflexes  are  normal,  and  its  onset  is  more 
gradual.  It  is,  however,  so  early  a  complication  of  rickets  that  its  recog- 
nition may  offer  difficulty. 

Infantile  paralysis  of  one  leg  may  produce  a  limp  in  gait  which  sug- 
gests congenital  dislocation  of  the  hip,  but  only  on  a  superficial  exami- 
'  Boston  Med.  and  Surg.  Journ. ,  vol.  i.,  p.  159,  1S99. 


426  ORTHOPEDIC  SURGERY. 

nation.  In  congenital  dislocation  the  trochanter  would  be  above  Nek- 
ton's line,  atrophy  would  be  very  slight,  and  the  electrical  reaction 
normal. 

With  hip  disease,  infantile  paralysis  is  at  times  confounded  in  prac- 
tice. The  onset  of  the  paralysis  may  be  accompanied  by  joint  pain  and 
tenderness,  and,  on  the  other  hand,  hip  disease  is  accompanied  by  mus- 
cular atrophy  and  a  modification  of  faradic  irritability  of  the  muscles. 
But  the  distinguishing  feature  of  hip  disease  is  muscular  fixation,  and 
that  is  not  present  in  infantile  paralysis,  in  which  muscular  laxity  is  the 
prevailing  condition.  The  onset  of  hip  disease,  although  generally 
gradual,  may  at  times  be  apparently  sudden. 

PROGNOSIS. 

So  far  as  danger  to  life  is  concerned,  the  outlook  in  infantile  paraly- 
sis is  very  favorable,  for  few  patients  die  in  the  acute  attack.  When 
death  does  occur  it  is  generally  at  the  end  of  a  week  or  ten  days.  Con- 
tinued cerebral  symptoms,  however,  are  of  grave  significance.  In  cases 
in  which  the  deformity  is  only  of  moderate  extent,  it  is  not  probable 
that  life  will  be  shortened  by  it. 

It  is  not  likely  that  the  paralysis  will  increase  if  it  has  been  station- 
ary for  twenty-four  hours.  Second  attacks  are  very  rare,  and  when 
they  do  occur,  they  come  on  within  a  day  or  two  of  the  original  attack 
and  are  made  evident  by  an  increase  of  the  existing  paralysis. 

The  tendency  of  the  paralysis,  as  we  have  seen,  is  toward  improve- 
ment and  partial  recovery.  The  law  of  Duchenne  suggests  a  more 
exact  prognosis  in  the  fact  that  all  the  paralyzed  muscles  in  which  the 
faradic  irritability  is  only  more  or  less  diminished,  but  not  completely 
lost,  during  the  course  of  the  second  week,  do  not  remain  permanently 
paralyzed,  the  restoration  being  more  prompt  and  complete  the  less  the 
faradic  irritability  has  been  diminished.  In  general,  when  the  faradic 
irritability  is  lost  at  once,  paralysis  will  be  severe  and  to  a  certain  ex- 
tent permanent.  When  the  irritability  is  lost  later,  the  paralyzed  mus- 
cles will  improve  slowly  and  nearly  recover.  When  faradic  irritability 
is  not  lost  at  all,  recovery  will  take  place  in  a  few  weeks  or  months. 
W^ithout  the  use  of  electricity  one  has  to  wait  much  longer  before  giv- 
ing any  more  definite  prognosis  than  a  general  promise  of  improve- 
ment. 

When  untreated,  a  case  of  infantile  paralysis  will  almost  invariably 
improve  for  one  or  two  months  at  a  rapid  rate,  then  more  slowly  for 
two  or  three  months  more,  and  then  after  a  stationary  period,  contrac- 
tions, looseness  of  the  joints,  and  malpositions  are  likely  to  begin, 
which  may  increase  indefinitely.  Under  treatment  the  prognosis  is 
much  more  favorable  and  the  limit  of  possible  improvement  extended 
by  many  years. 


ANTERIOR  POLIOMYELITIS.  427 

It  should  be  remembered  that  even  in  mild  cases  of  infantile  paral- 
ysis bone  shortening'  may  follow.  Certain  severe  cases  escape  with  but 
little,  while  a  mild  case  of  talipes  valgus  may  show,  with  the  wasting  of 
the  leg',  a  shortening-  of  one  or  two  inches  in  the  limb  of  the  affected 
side,  or,  in  exceptionally  severe  cases,  shortening  of  several  inches. 

A  large  measure  of  success  in  the  orthopedic  treatment  of  infantile 
paralysis  in  the  stage  of  deformity  can  be  expected  in  a  large  percen- 
tage of  cases,  exclusive  of  the  hopeless  class  where  a  large  portion  of 
the  body  is  permanently  paralyzed.  If  correction  of  the  deformity, 
mechanical  treatment,  massage,  dry  heat,  and  all  practicable  use  of  the 
limb  aided  by  apparatus  be  begun  at  as  early  a  stage  as  possible,  devel- 
opment of  the  strength  of  many  muscles  not  completely  paralyzed,  but 
weakened  from  disuse  after  the  original  onset  of  the  disease,  can  be 
expected,  materially  benefiting  the  patient.  This  can  be  supplemented 
if  necessary  by  tendon  transference  or  arthrodesis.  By  thorough  sur- 
gical care  what  would  be  a  condition  of  hopeless  affliction  can  be  con- 
verted into  a  slight  or  endurable  disability. 

TREATMENT. 

The  treatment  of  infantile  paralysis  varies  according  to  the  stage  at 
which  treatment  is  to  be  undertaken,  and  is  either  stimulative  to  check 
the  paralysis,  or  corrective  to  prevent  or  improve  deformity.  For  the 
latter  purpose  it  is  either  mechanical  or  operative. 

The  Stage  of  Onset. — If  the  fact  that  paralysis  is  present  is  estab- 
lished during  the  febrile  attack,  which  is  usually  the  first  symptom  of 
the  disease,  vigorous  treatment  should  be  at  once  begun,  to  limit,  if 
possible,  the  destructive  process  in  the  cord.  Cathartics  should  be 
given  at  once,  the  patient  should  lie  on  the  side  or  the  belly,  to  prevent 
stasis  of  the  blood  in  the  spinal  cord,  and  counter-irritants  or  cups 
should  be  applied  over  the  spine.  Ergot  should  be  administered  in 
doses  of  ten  drops  of  the  fluid  extract,  three  times  a  day,  for  infants  of 
six  months,  and  half  a  drachm  for  children  of  one  or  two  years.  Bro- 
mide of  potassium  and  of  sodium  and  strychnia  are  recommended. 
The  general  condition  of  the  child  should  in  every  way  be  kept  as  good 
as  possible.     Antipyretics  may  be  indicated. 

The  Stage  of  Paralysis. — But  few  cases  are  seen  by  the  surgeon 
until  the  stage  of  paralysis  is  present,  when  treatment  by  medicine  is 
manifestly  of  little  avail.  The  question  that  then  presents  itself  is  in 
regard  to  the  treatment  of  the  paralysis,  in  order  that  the  ultimate 
amount  of  muscular  power  may  be  as  great  as  possible.  It  must  be 
remembered  that  the  tendency  of  the  paralysis  is  at  first  very  strong 
toward  spontaneous  improvement.  It  is  therefore  manifest  that  in  the 
first  few  weeks  treatment  should  be  directed  toward  producing  condi- 


42  8  ORTHOPEDIC  SURGERY. 

tions  which  shall  be  as  favorable  as  possible  for  that  improvement  to 
attain  its  maximum. 

The  object  of  treatment  in  this  stage  should  therefore  be,  first,  to 
support  the  affected  limb  in  a  normal  position,  and  most  carefully  guard 
against  the  stretching  of  joints  and  ligaments  and  muscles;  and,  sec- 
ondly, by  the  use  of  electricity,  massage,  and  systematic  exercise  to 
keep  the  nutrition  of  the  affected  muscles  in  the  best  possible  condi- 
tion. In  this  way  only,  by  beginning  the  treatment  at  the  first,  can 
the  best  possible  ultimate  result  be  obtained. 

It  has  been  seen  that  what  may  be  called  protective  treatment 
should  be  begun  at  once,  and  from  the  first  the  diseased  limb  should  be 
placed  and  retained  in  a  normal  position,  so  that  the  affected  muscles 
and  joints  maybe  supported  and  kept  at  rest  and  relaxed.  In  this  way 
the  enfeebled  muscles  are  placed  under  the  best  possible  conditions  for 
their  recovery.  To  allow  attention  to  be  diverted  from  these  very 
important  measures  to  pursue  a  medical  treatment  whose  utility  is 
doubtful,  is  manifestly  irrational.  In  paralysis  of  the  legs  the  feet 
should  be  supported  from  the  first  at  a  right  angle,  in  their  normal  posi- 
tion, by  some  simple  splint  or  similar  appliance,  and  the  weight  of  the 
bed  clothes  should  be  kept  off  of  the  toes. 

The  appliances  needed  to  maintain  in  a  proper  position  the  limbs  of 
a  patient  with  paralysis  will  vary  according  to  the  parts  affected  and 
will  demand  some  ingenuity  on  the  part  of  the  surgeon.  In  severe  and 
extensive  cases  light  bed  frames  may  be  very  useful  to  allow  the  patient 
to  be  carried  about,  while  retaining  the  limbs  in  a  proper  position.  So 
far  as  possible  in  such  cases  bandages  should  be  avoided,  and  straps 
should  be  used  instead,  as  the  surface  circulation  is  feeble  and  likely  to 
be  impeded  by  bandages. 

When  the  arm  is  paralyzed,  a  sling  should  be  worn  to  prevent  drag- 
ging of  the  arm  upon  the  shoulder-joint  ligaments  and  the  weakened 
deltoid  muscle,  or,  if  the  deltoid  is  chiefly  affected,  the  arm  may  be  sup- 
ported on  a  frame  holding  it  at  right  angles  to  the  trunk. 

Electricity  is  a  most  useful  therapeutic  measure  in  the  early  stages 
of  the  paralysis.  Treatment  should  be  begun  as  early  as  the  spinal 
irritation  seems  to  have  disappeared,  probably  about  the  end  of  the 
first  week,  and  continued  indefinitely,  but  not  to  the  exclusion  of  proper 
mechanical  treatment.  The  galvanic  current  is  used ;  a  very  gentle  cur- 
rent is  passed  through  the  affected  muscles  and  nerves  for  a  few  min- 
utes each  day,  and  muscles  which  contract  only  feebly  to  faradism 
should  be  daily  stimulated  by  the  application  of  the  faradic  current. 
^Muscles  which  will  not  contract  to  faradism  can  sometimes  be  much 
improved  by  applications  of  the  interrupted  galvanic  current.  The 
chief  use  of  electricity,  it  is  to  be  remembered,  is  to  stimulate  to  con- 
traction the  paralyzed  muscles,  thereby  affording  a  sort  of  gymnastics. 


ANTERIOR  POLIOMYELITIS. 


429 


Probably  electrical  treatment  receives  much  cieclit  in  the  treatment  of 
this  disease,  which  is  not  improperly  clue  to  it,  for  it  is  employed  at  a 
time  when  marked  improvement  is  almost  certain,  and  very  much  the 
same  results  can  be  obtained  by  methods  about  to  be  considered.  One 
sees  cases  in  which  it  has  ceased  to  benefit  the  child  and  has  been  per- 
sisted in  to  the  exclusion  of  more  rational  treatment  for  that  especial 
case.  But  even  in  the  late  stages  of  the  disease,  when  wasting  and 
deformity  have  come  on,  the  use  of  electricity  may  at  times  lead  to  an 
improvement  of  nutrition. 

Dry  warmth  and  rubbing  are  measures  which  seem  of  equal,  if  not 
of  greater,  value  in  the  stage  of  simple  paralysis.  Heat  is  easily  ap- 
plied by  having  the  child  sit  in  front  of  a  fire  or  stove  with  the  leg 


Fig.  383.— Clawed  Toes  and  Pes  Cavus  following  Infantile  Paralysis. 

thrust  through  a  hole  in  a  sheet  of  pasteboard.  This  serves  as  a  screen 
to  the  rest  of  the  body,  while  the  affected  member  is  allowed  to  become 
thoroughly  warmed  once  or  twice  a  day  either  in  this  way  or  by  a  hot- 
air  oven.  During  the  day,  especially  in  cold  weather,  the  paralyzed  limb 
should  be  protected  by  two  thick  stockings  and  a  warm  boot.  Any 
treatment  which  stimulates  the  circulation  of  the  paralyzed  limb  aids 
in  its  recovery  by  improving  the  nutrition  of  the  muscles,  and  dry  heat 
very  effectually  accomplishes  this  end.  A  paralyzed  leg  should  be 
thoroughly  heated  for  an  hour  before  it  is  rubbed  at  night. 

Massage  is  another  most  important  element  of  treatment  in  this  as 
in  any  stage  of  infantile  paralysis  after  the  initial  irritation  has  quieted 
down.  Skilled  massage,  when  it  can  be  obtained,  is  of  course  better 
than  friction  at  the  hands  of  the  parents,  but  the  latter  is  a  simple  and 
efficient  treatment,  which  lies  within  the  reach  of  most  people. 

In  the  place  of  the  usual  manual  massage,  mechanical  massage  of 
the  limbs  has  been  employed  by  means  of  carefully  constructed  appli- 
ances.    This,  however,  will  be  within  the  reach  of  but  few. 


430  ORTHOPEDIC  SURGERY. 

Active  muscular  exercise  of  the  paralyzed  limb  is  a  most  desirable 
tonic  to  the  affected  muscles,  however  it  is  obtained,  provided  the  mus- 
cles be  not  overtaxed.  With  the  assistance  of  the  parent's  hand,  a  foot 
which  naturally  drops  forward  from  paralysis  of  the  anterior  leg  mus- 
cles can  be  flexed,  and  with  each  repetition  of  the  exercise  the  muscle 
may  be  found  able  to  accomplish  more.  It  is  impossible  to  lay  down 
any  series  of  exercises.  In  each  case  the  problem  must  be  met  differ- 
ently. The  aim  should  be  so  to  assist  the  affected  muscles  that  if  they 
have  any  power  left  they  may  be  enabled  to  use  it  daily  for  their  own 
advantage.  And  with  this  in  view,  assistance  should  be  rendered  by 
supporting  and  aiding  the  affected  limb  in  its  movements  in  the  way 
most  likely  to  call  into  use  these  paralyzed  muscles.  Such  exercise 
forms  a  most  useful  adjunct  to  the  massage.  It  should  be  repeated 
each  night  just  before  or  just  after  the  massage. 

H.  L.  Taylor,  in  an  excellent  paper  on  the  hygiene  of  reflex  action, 
says :  "  In  the  neuromuscular  degenerations  following  acute  anterior 
poliomyelitis,  it  is  especially  important  to  restore  to  the  paretic  extrem- 
ities, so  far  as  possible,  the  stimuli  of  locomotion  and  other  normal 
associated  movements  without  the  inhibition  of  insecure  footing  and 
strained  tissues— and  it  is  for  the  specific  purpose  of  restoring  to  the 
damaged  cord  and  muscles  the  cutaneous,  muscular,  and  articular  stim- 
uli of  locomotion  that  apparatus  is  constructed." 

Mechanical  Treatment. 

The  mechanical  treatment  of  infantile  paralysis  is  twofold  in  its  ob- 
ject. The  first  and  simplest  use  of  apparatus  is  to  support  and  protect 
the  paralyzed  limb  in  such  a  way  that  the  muscles  shall  work  to  the 
best  advantage  and  that  the  joints  may  be  supported  and  controlled. 
By  doing  this  the  occurrence  of  contraction  deformities  is  prevented 
and  the  nutrition  of  the  limb  is  kept  in  the  best  possible  condition  by 
enabling  the  limb  to  be  used  in  a  comparatively  normal  way. 

The  second  function  of  mechanical  treatment  in  infantile  paralysis 
is  to  overcome  by  means  of  suitable  appliances  deformities  which  have 
already  occurred  and  to  prevent  their  recurrence ;  it  may  often  be  nec- 
essary to  attempt  both  objects  with  one  apparatus. 

The  Indications  for  Mechanical  Treatment. — Whenever  a  paralyzed 
limb  is  unable  to  bear  the  weight  of  the  body  which  falls  upon  it  in 
locomotion,  some  mechanical  help  is  manifestly  advisable.  This  is  not 
only  needed  when  the  paralysis  is  complete,  but  also  when,  owing  to 
incomplete  muscular  strength,  more  strain  is  borne  on  the  articular  lig- 
aments than  is  normal.  Moreover,  when  the  bearing  of  the  body-weight 
or  the  act  of  walking  throws  the  foot  or  the  leg  into  any  abnormal  po- 
sition, the  use  of  some  appliance  is  indicated.     It  is  difificult  to  describe 


ANTERIOR  POLIOMYELITIS.  43 1 

the  various  appliances  needed  in  the  treatment  of  infantile  paralysis^ 
and  much  must  be  left  to  the  ingenuity  of  the  surgeon  m  each  case. 

Paralysis  of  the  Leg. — When  the  muscles  of  the  leg  are  paralyzed, 
those  which  help  to  control  the  ankle-joint  in  standing  and  walking  are 
rendered  inefficient  and  the  ligaments  may  become  relaxed,  so  that  in 
the  standing  position  the  ankle  of  the  affected  side  cannot  sustain  the 
body-weight  as  it  should,  and  the  foot  is  apt  to  roll  in  or  out,  causing 
an  inversion  or  eversion  of  the  foot  amounting  to  a  degree  of  talipes 
varus  or  valgus. 

In  any  apparatus  which  is  to  sustain  the  foot  in  its  weight-bearing 
function,  accuracy  of  support  is  indispensable,  and  a  simple  leather 
boot,  however  stout  it  may  be,  soon  yields  and  the  foot  slips  away  from 
the  rest  of  the  apparatus,  and  the  efficiency  of  the  brace  is  impaired ;  a 
rigid  sole  is,  therefore,  essential  for  any  apparatus  which  is  to  control 
the  ankle  properly,  and  this  can  easily  be  accomplished  by  having  a 
thin  steel  plate  inserted  between  the  layers  of  the  sole  of  the  boot. 

When  no  contraction  or  deformity  exists  at  the  ankle,  but  there  is 
simply  a  tendency  of  the  front  of  the  foot  to  drop  on  account  of  the 
affection  of  the  anterior  muscles  of  the  leg,  locomotion  can  be  made 
much  more  easy  by  preventing  this.  A  common  appliance  for  this  lat- 
ter deformity  is  an  ordinary  shoe  fitted  with  lateral  steel  uprights  and 
a  posterior  steel  calf  band  (Chapter  XXI.,  28).  There  is  a  right-angle 
stop  catch  at  the  ankle  which  keeps  the  foot  from  dropping. 

The  same  end  can  be  better  accomplished  by  the  application  of  a 
walking  appliance,  described  under  club-foot  as  an  equino-varus  shoe,, 
which  should  be  provided  with  a  right-angle  stop  at  the  ankle  which 
will  not  allow  the  ankle  to  be  extended  to  more  than  a  right  angle 
(Chapter  XXL,  37).  When  in  bearing  weight  upon  the  leg  the  ankle 
assumes  a  varus  position,  a  varus  shoe  will  correct  the  tendency  to  de- 
formity (Chapter  XXI.,  30). 

If  the  foot  rolls  out  and  is  everted  into  a  valgus  condition  when  the 
body  weight  is  borne  upon  the  leg,  an  outside  shoe  is  to  be  applied,  in 
construction  like  the  varus  shoe,  but  which  should  have  a  broad  leather 
strap  which  should  pass  around  the  inner  malleolus  and  support  it 
(Chapter  XXL,  31).  This  apparatus  is  a  difficult  one  to  render  quite 
comfortable  to  the  patient,  as  much  weight  must  necessarily  come  upon 
the  strap  which  supports  the  inner  malleolus.  As  flat-foot  is  almost 
always  present  in  these  cases,  it  is  well  to  arch  the  steel  sole  plate  of 
this  apparatus  so  that  it  serves  as  a  valgus  plate  as  well  as  a  support- 
ing appliance. 

If  calcaneus  is  present  the  apparatus  spoken  of  for  equinus  is  used, 
with  the  stop  catch  reversed  to  prevent  dorsal  instead  of  plantar  flexion 
(Chapter  XXL,  39). 

Pes  cavus  may  be  treated  by  inserting  a  steel  sole  in  the  sole  of  the 


432  ORTHOPEDIC  SURGERY. 

boot  and  passing  a  strap  from  the  sole  over  the  dorsum  of  the  foot. 
This  treatment  is  made  much  more  efficient  if  combined  with  prehmi- 
nary  division  of  the  plantar  fascia.  Mechanical  treatment  alone  is 
likely  to  be  unsatisfactory. 

Talipes  calcaneus  may  be  treated  by  fixing  the  foot  for  months  in 
a  position  of  talipes  equinus  by  means  of  a  plaster  bandage.  At  the 
end  of  this  time  a  shortening  of  the  muscles  at  the  back  of  the  leg  will 
be  found.' 

It  is  manifest  that  the  simpler  and  lighter  these  appliances  are  and 
the  less  unsightly,  the  more  serviceable  they  will  prove.  For  this  rea- 
son they  should  be  carefully  fitted  and  the  uprights  made  to  follow  the 
outline  of  the  leg.  In  very  slight  cases,  in  which  there  is  only  a  slight 
eversion  of  the  foot  with  a  small  degree  of  valgus,  a  common  valgus 
plate  (Chapter  XXI.,  32),  such  as  would  be  applied  for  flat-foot,  will 
often  answer  every  purpose  in  correcting  the  deformity,  and  it  should 
be  applied  as  in  simple  flat-foot. 

In  severe  cases  of  paralysis  of  the  muscles  of  the  legs  and  foot,  the 
thigh  muscles  may  be  involved.  The  same  appliance  will  often  have  to 
support  the  knee  and  thigh  as  well  as  to  correct  deformity  at  the  ankle. 
But  this  involves  merely  an  extension  of  the  apparatus  up  the  leg. 

Paralysis  of  the  Thigh  Muscles. — When  the  muscles  of  the  thigh 
are  involved  in  the  paralysis,  the  limb  becomes  unable  to  sustain  the 
weight  thrown  upon  it  and  the  knee  flexes  and  the  limb  drops  forward 
Avhen  weight  is  borne  upon  it.  The  knee-joint  does  not  bend  to  one 
side  or  the  other,  as  the  lateral  ligaments  retain  much  strength.  In  a 
few  instances  the  knee  will  drop  backward  to  more  than  a  straight  line, 
but,  owing  to  the  strength  of  the  crucial  ligaments  in  infantile  paraly- 
sis, it  never  falls  so  far  back  as  to  be  unable  to  sustain  weight.  For  the 
practical  purposes  of  locomotion,  therefore,  it  is  only  essential  that  the 
knee  be  prevented  from  dropping  forward,  and  this  can  be  done  by 
means  of  any  appliance  which  will  press  the  knee  backward.  The  sim- 
plest way  of  doing  this  is  by  the  use  of  two  steel  rods  reaching  from 
the  back  of  the  thigh  to  the  bottom  of  the  shoe  (Chapter  XXI.,  25), 
connected  at  the  top  by  a  posterior  steel  band,  which  furnishes  a  coun- 
terpoint of  pressure  by  which  to  hold  the  knee.  If  a  strap  is  passed  in 
front  of  the  knee,  it  is  impossible  for  it  to  drop  forward  when  weight  is 
thrown  upon  the  leg,  and  the  patient  can  stand  upon  the  limb.  The 
appliance  supplies  the  check  normally  exercised  by  the  muscles.  Be- 
low it  should  be  fitted  to  a  boot,  or,  if  the  muscles  of  the  leg  are  also 
involved,  to  one  of  the  appliances  such  as  the  varus  or  valgus  shoe  men- 
tioned above. 

Instead  of  being  applied  by  means  of  a  steel  sole  plate,  the  appara- 
tus may  be  fastened  to  the  sole  of  the  boot  (Chapter  XXI.,  26).  In 
'  Gibney  :  Medical  News,  1900,  Ixxvii.,  399. 


ANTERIOR   POLIOMYELITIS, 


433 


addition  to  the  bands  shown  in  the  figure,  leather  lacings  to  retain  the 
thigh  and  calf  will  probably  be  needed  to  give  the  apparatus  greater 
stability,  as  the  lacings,  by  covering  a  large  area  of  skin,  substitute  sur- 
face pressure  for  the  point  press- 
ure    given    by    narrow    straps. 
This  is  a  matter  to  be  considered 
in  all  supporting  apparatus. 


Fig.  384.— Supporting  Splint  for  Infantile 
Paralysis  of  the  Leg. 


Fig.  385.— Supporting-  Splint  for  Use  in  In- 
fantile Paralysis.  It  prevents  ilexion  of 
the  knee  in  standing,  but  is  provided  with 
a  lock-joint  at  the  knee. 


If  the  knee  tends  to  drop  backward  and  become  hyperextended,  it 
can  be  remedied  by  a  similar  appliance  with  a  strap  passing  behind  the 
knee,  with  an  upper  band  encircling  the  thigh.  In  practice  this  appa- 
ratus can  often  consist  of  a  single  outside  upright  hinged  at  the  knee. 
It  passes  to  the  inside  of  the  leg  just  below  the  knee  to  become 
attached  to  a  varus  shoe.  This  answers  as  well  as  a  double  upright  in 
28 


434 


ORTHOPEDIC  SURGERY. 


many  cases.  The  apparatus  can  be  hinged  at  the  knee  for  convenience 
in  sitting  down  and  should  be  furnished  with  leather  lacings  for  the 
thigh  and  calf  (see  Figs.  384  and  385). 

Other  cases,  in  which  the  paralysis  is  more  severe,  require  the  two 
uprights,  as  they  furnish  a  more  definite  support.     The  foot  is  easily 


Fig.  386. — Jacket  Attached  to  Caliper  Splints  Applied  to  a  Case  of  Paralysis  of  the  Trunk 

aud  of  Both  Legs. 

retained  to  the  steel  sole  plate  by  straps  or  a  piece  of  leather  lacing 
over  the  instep.  The  fenestrated  knee  cap  is  the  most  comfortable 
method  of  holding  the  knee  extended. 

Although  in  walking  it  is  generally  necessary  to  have  the  knee  kept 
extended  by  the  splint,  yet  in  sitting  down  it  is  a  great  comfort  to  the 
patient  to  be  able  to  flex  the  knee,  and  for  this  reason  nearly  all  splints 
should  be  hinged  at  the  knee. 

A  great  variety  of  hinges  can  be  applied  at  the  knee  with  different 
catches,  enabling  the  patient  to  bend  the  limb  b}^  loosening  the  catch 
or  locking  it  when  it  is  desired  that  the  limb  should  be  stiff.  The  sim- 
plest and  most  economical  of  these  is  the  simple  drop  catch  shown  in 
the  figure.     When  the  limb  is  straightened,  the  ring  falls  down  and 


ANTERIOR  POLIOMYELITIS.  435 

locks  the  splint  in  the  extended  position,  but  it  can  ])c  pulled  up  at  any 
time,  allowing  the  knee  to  bend. 

In  another  and  more  expensive  form  the  splint  is  self-locking,  and 
the  bending  is  made  possible  by  pressing  a  handle  at  the  outside  of  the 
knee. 

When  the  adductor  muscles  are  affected,  little  or  nothing  can  be 
done  to  supplement  them  by  mechanical  means  without  employing 
heavy  apparatus,  inasmuch  as  their  loss  of  power  occurs  only  in  exten- 
sive paralysis.  Little  can  be  done  to  remedy  paralysis  of  the  glutei 
muscles,  but  when  paralysis  of  the  legs  appears  to  be  complete,  a  cer- 
tain amount  of  relief  may  be  given  by  attaching  the  leg  uprights  to  a 
leather  or  silicate  jacket.  The  common  Thomas  knee  splint  (Chapter 
XXI.,  14)  may  be  joined  to  a  leather  jacket  (Chapter  XXI.,  3) by  lat- 
eral uprights  jointed  at  the  trochanters. 

The  muscles  of  the  back  are  rarely  if  ever  paralyzed,  except  in  con- 
nection with  palsy  of  some  of  the  muscles  of  the  leg.  Complete  paral- 
ysis of  the  muscles  of  the  trunk  indicates  an  extent  of  disease  which  is 
most  distressing.  When  the  muscles  of  the  back  are  but  partiall}-- 
affected,  help  may  be  afforded  by  the  use  of  corsets  or  other  supporting 
appliances,  such  as  are  employed  in  the  deformities  of  the  spine. 
These  can  be  connected  with  the  leg  appliances  and  will  afford  assist- 
ance in  standing.  Cases  of  this  sort  may  be  so  severe  as  to  require  the 
use  of  crutches  for  rapid  locomotion,  but  much  assistance  may  be 
afforded  by  appliances  in  many  cases. 

The  abdominal  muscles  are  sometimes,  though  rarely,  affected,  giv- 
ing a  protuberant  abdomen  and  a  position  of  much  lordosis  in  standing. 
Waist  bands  or  corsets  will  serve  to  correct  the  malposition  of  the 
trunk  to  a  certain  extent. 

The  mechanical  treatment  of  infantile  paralysis  of  the  arm  is  not  a 
question  which  arises  often  enough  to  make  it  worth  while  to  enter 
upon  any  discussion  of  it,  save  to  mention  that  the  principles  of  treat- 
ment are  the  same  as  those  already  considered. 

The  use  of  elastic  bands  to  supply  the  place  of  the  disabled  muscles 
is  thought  in  some  instances  to  be  sufficient  to  compensate  for  the 
action  of  the  paralyzed  muscles.  It  will,  however,  be  found  that  an 
elastic  support,  inasmuch  as  it  is  not  of  certain  tension,  is  necessarily  a 
varying  support  and  adds  to  the  complicated  nature  of  the  appliance 
rather  than  to  its  efficiency,  nor  is  it  possible  to  gauge  accurately  the 
force  or  pressure  exerted  at  any  time.  It  is  generally,  therefore,  a 
much  less  efficient  form  of  apparatus  than  the  rigid  forms  here  advo- 
cated. 

Mechanical  Treatment  as  Applied  to  the  Correction  of  the  Deformity. 
— Whether  the  deformity  shall  be  corrected  by  purely  mechanical 
means  or  by  operative  interference  depends  not  only  upon  the  nature 


436 


ORTHOPEDIC  SURGERY. 


of  the  distortion,  but  also  upon  the  time  at  the  disposal  of  the  patient 
and  surgeon.  Many  of  the  distortions  of  this  sort  can  be  cured  in  chil- 
dren without  any  operative  interference,  as  all  that  is  required  is  the 
stretching  of  the  fasciae  and  the  contracted  tendons.  These  distortions 
are  either  flexions  at  the  hip  or  knee  or  some  distortion  of  the  ankle. 
The  less  severe  of  these  distortions  yield  readily  upon  the  application 
of  efficient  force. 

Deformity  at  the  hip,  which  is  generally  flexion,  with  perhaps  abduc- 
tion, is  the  hardest  of  all  the  deformities  of  infantile  paralysis  to  correct 
by  mechanical  means,  on  account  of  the  difficulty  of  securing  a  fixed 
hold  upon  the  pelvis,  by  which  a  point  of  resistance  can  be  secured  in 
overcoming  the  flexion  of  the  thigh.  A  simple  apparatus  which  is 
often  of  use  is  furnished  by  two  caliper  Thomas  knee  splints  (Chapter 
XXI.,  15),  or  one,  as  the  case  may  be,  attached  to  a  leather  jacket  by 
side  irons  hinged  opposite  to  the  hips.  To  the  posterior  and  upper 
parts  of  the  splints  are  attached  straps  which  buckle  to  the  back  of  the 


Fig.  3S7.  Fig.  38S. 

Pigs.  387  and  3S8.— Supporting-  Apparatus  in  ParaU-sis  of  Anterior  Thigh  Muscles. 

jacket,  and  while  by  the  jacket  as  firm  a  hold  as  possible  is  taken  on 
the  pelvis,  when  the  straps  are  buckled  the  caliper  splints  pull  the  legs 
backward  and  tend  to  overcome  the  flexion  at  the  hips.  During  this 
time  the  child  should  go  about  on  crutches. 

But  the  contraction  is  sometimes  resistant,  and  it  is  necessary  to 
confine  the  patient  to  the  bed  and  to  employ  traction  of  a  considerable 
amount  and  such  measures  as  have  already  been  described  in  correc- 
tion of  the  flexion  deformity  of  hip  disease. 


ANTERIOR   POLIOMYELITIS. 


437 


Attempts  to  use  the  weight  oi  the  leg  to  correct  this  flexion  in  se- 
vere cases  are  of  little  use.  It  might  be  imagined  that  if  the  knee  were 
straightened  by  a  ham  splint,  and  the  patient  allowed  to  go  about  on 
crutches  with  the  leg  projecting  in  front  of  him,  the  weight  of  it  by- 
dragging  upon  the  shortened  tissues  would  stretch 
them  and  the  flexion  at  the  hip  would  be  dimin- 
ished. But  the  leg  hangs  almost  perpendicu- 
larly in  these  cases,  owing  to  a  compensatory 
lordosis  in  the  lumbar  spine,  which  takes  place  at 
once.  This  is  due  to  the  rotation  of  the  pelvis 
upon  its  transverse  axis,  which  occurs  under  the 
influence  of  the  weight  of  the  leg  and  which  oc- 
casions no  inconvenience  to  the  patient.  A  sim- 
ilar proceeding  occurs  when  a  weight  is  applied 
to  the  patient's  leg  lying  in  bed,  so  that  it  be- 
comes inefificient  also.  In  the  severer  cases  op- 
erative treatment  is  indicated. 

Flexion  of  the  knee  is  due  to  a  contraction  of 
the  hamstring  muscles.  The  deformity  in  chil- 
dren, except  in  severe  cases,  can  be  corrected  by 
bandaging  the  leg  to  a  splint  which  takes  press- 
ure above  on  the  under  side  of  the  thigh  and 
below  is  fastened  to  the  heel.  The  appliance  is 
similar  to  that  described  above  as  a  support  to 
the  knee.  In  resistant  cases  some  pain  is  expe- 
rienced in  this  procedure,  but  the  pain  is  not 
great.  Patients  with  severe  deformity  should  be 
confined  to  bed  during  the  application  of  this 
method  of  treatment,  but  in  the  milder  cases  they 
may  be  allowed  to  go  about. 

The  simplest  of  all  forms  of  correction  in  contraction  of  the  knee  is 
the  Thomas  knee  splint  (Chapter  XXL,  14)  or  a  modification  of  it,  but 
jointed  splints  will  be  found  convenient  in  some  instances  of  the  sever- 
est type.  If  the  Thomas  knee  splint  is  applied,  a  bandage  should  be 
applied  in  front  of  the  thigh  and  behind  the  calf;  by  tightening  these  a 
decided  extension  force  is  exerted  upon  the  knee. 

A  more  complicated  brace  for  correction  of  the  knee  is  one  similar 
to  the  simple  supporting  brace  with  two  uprights  already  described 
(Chapter  XXI.,  26),  except  that  it  is  jointed  at  the  knee  and  furnished 
on  one  side  with  a  worm  screw  and  ratchet,  so  that  by  the  use  of  a  key 
the  splint  can  be  set  with  any  desired  angle  at  the  knee.  A  leather 
knee  cap  is  sometimes  necessary  to  obtain  counter-pressure  against  the 
knee  in  front,  but  in  other  cases  the  thigh  and  calf  lacings  are  sufficient 
to  obtain  any  desired  leverage.     These  leather  lacings  should  fit  with 


Fig.  389.— Splint  with  Sin- 
gle Upright  for  Infantile 
Paralysis  of  Right  Leg 
with  Varus  Deformity  of 
Ankle. 


43 S  ORTHOPEDIC  SURGERY. 

especial  accuracy  in  this  form  of  appliance.  To  be  applied  the  splint 
should  be  flexed  to  fit  the  contracted  knee  and  put  on  and  laced  firmly. 
Then  with  the  key  it  should  be  extended  nearly  to  the  point  of  endurance 
and  worn  as  straight  as  it  can  be  borne  for  an  indefinite  time.  At  first 
these  sub-joints  may  prove  sensiti\'e  and  painful,  but  they  soon  become 
used  to  the  tension  and  then  rapid  progress  can  be  made.  The  exten- 
sion of  a  contracted  knee  may  in  the  case  of  an  adult  be  a  matter  of 
many  months,  but  in  children  it  requires  less  time,  unless  it  is  severe, 
when  operation  ma\"  be  required.  The  deformity  shows  a  strong  ten- 
dencv  to  recur  when  the  apparatus  is  removed. 

Correction  b}"  the  repeated  application  of  plaster  bandages  to  the 
knee,  extended  as  much  as  possible,  will  often  be  found  satisfactory 
and  pamless  to  the  patient.  This  can  be  facilitated  by  inserting  a 
hinge  joint  in  the  plaster  at  the  knee,  and  b}"  cutting  awa}'  the  plaster 
around  the  leg  at  the  Ie\'el  of  the  hinges  it  may  be  used  as  a  straight- 
ening appliance.  The  method,  however,  is  a  slow  one  in  resistant  de- 
formities. 

Deformities  of  the  Feet. — The  mechanical  correction  of  deformities 
of  the  foot  caused  by  infantile  paralysis  is  so  much  more  tedious  than 
Avhen  operative  measures  are  used  that  the  majority  of  surgeons  much 
prefer  the  latter  method.  In  the  less  resistant  cases,  however,  correc- 
tion of  paralytic  cases  can  be  effected  by  plaster-of-Paris  bandages  re- 
peatedly applied  to  feet  forcibh'  held  in  as  near  a  corrected  position  as 
possible.  Slight  paralytic  deformities  of  the  feet  can  also  be  corrected 
by  fixing  the  feet  in  the  walking  appliances  used  for  the  various  forms 
of  talipes,  arranged  so  as  to  prevent  motion  in  the  direction  of  contrac- 
tion, but  allowing  motion  in  other  directions.  The  weight  of  the  patient 
at  every  step  acts  as  a  correcting  force. 

OPERATIVE    TREATMENT. 

The  object  of  operative  interference  in  paralytic  affections  is  two- 
fold : 

I  St.  To  correct  existing  deformity. 

2d.  To  render  the  paralyzed  limb  more  efficient. 

For  a\-erage  cases  of  post-paralytic  deformity,  forcible  manual  cor- 
rection with  or  without  the  aid  of  tenotom}",  with  muscle-stretching 
and  perhaps  fasciotomy,  are  sufficient  for  correction.  The  deformities 
to  be  corrected  are  flexions  at  the  hip  and  knee,  and  the  distortions  of 
the  feet  classed  as  the  different  forms  of  talipes.  The  latter  can  be 
corrected  by  the  various  procedures  described  in  the  chapter  on  *'  Club- 
foot.■"■■  Paralytic  talipes,  however,  is  much  less  resistant  and  yields  to 
much  less  radical  measures  than  are  often  needed  in  congenital  club- 
foot, and  subcutaneous  tenotomy  and  fasciotomy  with  manual  correc- 
tion will  suffice  in  almost  all  cases. 


ANTERIOR  POLIOMYELiriS. 


439 


Flexion  at  the  knee  may  require  tenotomy  of  the  hamstring  muscles, 
which  is  more  thoroughly  performed  by  means  of  an  open  incision  than 
subcutaneously,  as  frequently  the  shortened  fasciae  need  division  as 
well  as  the  tendons.  In  order  to  prevent  a  gaping  wound  after  correc- 
tion, a  Y-shaped  or  longitudinal  skin  incision  should  be  used. 

An  open  incision  is  necessary  if  the  contractions  \\\  flexion  of  the  Jiip 
are  resistant.     These  are  usually  superficial  and  involve  the  fascia  lata, 

but  the  intramuscular  septa  of  the  deep  mus- 
l  *.^  cles  may  also  need  division  and  the  operation 

\         '\      "v  may  have  to  be  extensive.     In  the  older  cases 

in  which  alteration  in  the  shape  of  the  bone 
exists,  osteotomy  or  even  excision  may  be 
needed.  The  latter  is  rarely  indicated,  as 
linear  osteotomy  near  the  joint  will  enable 


Fig.  300. — Transplantation  of 
Sartorius  to  Quadriceps 
Tendon.     CGoldthwait.) 


Fig.  391. — Elongation  of  Tendo  Achillis.     (Berger  and 
Banzet.) 


the  surgeon  to  straighten  the  limb  with  less  destruction  of  tissue.  The 
measures  above  mentioned  do  not  aid  the  paralysis,  but  aid  locomotion 
with  or  without  the  necessary  appliances. 

Tendon  Transference.' — Measures  maybe  undertaken  for  the  direct 

'  O.  A'ulpius :  "Die    Sehneniiberpflanzung."  etc..   Leip.sic,   1902    (with    bibli- 
ography). 


440  ORTHOPEDIC  SURGERY. 

purpose  of  aiding  the  paralyzed  muscles  with  the  view  of  making  loco- 
motion possible  without  the  need  of  appliances.  The  most  important 
of  these  are  the  operations  on  the  affected  muscles. 

Tendon  transplantation  or  tendon  anastomosis,  first  introduced  in 
1 88 1  by  Nicoladoni,  consists  of  a  procedure  by  which  the  proximal  ends 
of  healthy  or  partially  affected  muscles  are  inserted  in  or  attached  to 
the  distal  ends  of  the  tendons  of  paralyzed  muscles  or  to  the  perios- 
teum, and  the  action  of  the  healthy  muscle  is  transferred  to  the  attach- 
ment of  the  paralyzed  one  or  to  a  more  ef^cient  insertion.^ 

The  transference  of  one  tendon  to  another,  as  originally  intro- 
duced, has  been  extensively  employed  and  has  been  followed  by  a  cer- 
tain amount  of  success,  but  in  a  large  percentage  of  cases  the  ulti- 
mate results  have  not  been  so  beneficial  as  is  to  be  desired.  It  was 
found  that  the  functional  strength  of  the  transplanted  muscle  was 
rarely  equal  to  the  required  work.  Improvements  in  the  methods  have 
been  made  recently,  however,  which  have  increased  the  efficiency  of  the 
procedure. 

Periosteal  tendon  transference,  as  it  may  be  termed,  is  a  pro- 
cedure which  can  be  relied  upon  to  give  a  reasonable  amount  of  perma- 
nent success.  It  is  impossible  at  present  to  give  the  statistical  value 
of  the  procedure.  So  much  depends  upon  the  amount  of  strength  re- 
maining in  the  transferred  muscle  that  the  cases  are  difficult  to  group. 
For  success  it  is  essential  that  the  muscular  balance  in  the  paralyzed 
limb  be  restored,  and  for  this  it  is  necessary  that  the  transferred  mus- 
cle pass  as  directly  as  possible  from  its  origin  to  its  new  insertion ;  it  is 
essential  that  the  transferred  muscle  should  not  be  relaxed  and  that  it 
should  have  a  firm  and  an  effective  attachment.  The  transferred  ten- 
don should  be  given  a  periosteal  attachment,  if  possible,  at  such  a  point 
as  will  give  on  muscular  contraction  the  functional  result  of  the  re- 
quired motion.  When  the  tendon  is  not  long  enough  to  reach  to  the 
desired  point  of  insertion,  it  can  be  lengthened  by  the  use  of  strands  of 
braided  silk,  which  are  quilted  in  the  end  of  the  transferred  tendon,  and 
at  the  distal  end  sewed  into  the  periosteum  or  attached  to  the  proximal 
end  of  the  paralyzed  tendon. 

Lange,  who  originated  this  method,  has  demonstrated  not  only  that 
in  this  way  a  permanently  useful  tendon  can  be  furnished,  but  that  ap- 
parently fibrous  tissue  forms  about  the  silk  strands.  The  application 
of  the  method  varies  necessarily  with  the  deformity  and  the  part  para- 
lyzed, whether  it  is  for  a  paralytic  talipes  equino-varus,  a  valgus,  equi- 
nus,  calcaneus,  for  paralysis  of  the  extensor  cruris,  or  for  other  paral- 
yses. 

In  eqinno-vai'HS,  egtiino-valgns,  or  eqiiimis  the  procedure  is  some- 

^  Codivilla  :  Zeitsch.  f.  orth.  Chir.,  xii. — Vulpius  :  Ibidem.  — 'Ldiage.,  Schanz, 
and  Reiner:  Ibidem. — Koch:  Miinch.  med.  Woch.,  July  19th,  1904. 


ANTERIOR  POLIOMYELITIS. 


441 


i 


what  the  same.  The  operation  is  more  conveniently  done  after  the 
hmb  has  been  made  bloodless  by  the  Esmarch  method,  and  the  deform- 
ity of  varus,  valgus,  or  equinus  must  be  forcibly  corrected  with  tenoto- 
my and  fasciotomy  if  necessary.  The  correction  of  the  deformity 
should  be  preferably  done  a  few  days  before  the  tendon  operation.  A 
long  incision  is  then  made  over  the  middle  of  the  ankle  or  the  part  of 
the  ankle  where  the  tendons  to  be  operated  on  are  situated,  extending 
to  the  dorsum  of  the  foot.  The  muscle  to  be  transferred  is  then  se- 
lected and  the  tendon  isolated  and  cut  off  as  near  its  insertion  as  possi- 
ble. The  end  is  then  secured  by  a  long, 
stout,  silk  suture.  The  muscular  portion 
is  freed  above  sufficiently  to  permit  a 
transferrence  of  the  direction  of  the  mus- 
cle in  a  nearly  straight  rather  than  a 
curved  course.  The  desired  point  of  in- 
sertion is  then  selected,  which  should  be 
as  far  forward  on  the  tarsus  as  is  prac- 
ticable. The  silk  attached  to  the  freed 
tendon  is  then  stitched  securely  to  the 
periosteum  at  the  selected  point,  the 
tendon  pulled  tightly  into  its  new  posi- 
tion, and  firtnly  tied.  If  the  tendon  is 
too  short  to  reach,  its  length  can  be 
pieced  out  by  the  strong  silk  strands  of 
the  suture  or  it  may  be  stitched  into  the 
paralyzed  tendon  near  its  insertion,  but  a 
periosteal  insertion  is  much  to  be  pre- 
ferred. All  the  extensor  tendons  of  the 
foot,  if  relaxed,  whether  paralyzed  or  not,  are  to  be  shortened.  If  they 
are  paralyzed  they  can  be  used  as  a  stay  in  the  corrected  position,  and 
if  not  paralyzed  they  can  only  be  effective  if  sufficiently  tight.  The 
tendo  Achillis  should,  of  course,  be  divided  when  necessary. 

It  is  evident  that  the  length  and  the  site  of  the  skin  incision  varies 
with  the  surgeon's  judgment  and  with  the  muscle  to  be  transferred. 
Whether  the  tibialis  anticus  or  the  peroneus  longus  is  selected  depends 
upon  the  location  of  the  paralysis  and  will  affect  the  position  of  the 
skin  incision.  When  the  anterior  group  of  muscles  are  all  paralyzed, 
as  in  talipes  equinus,  a  portion  of  the  tendo  Achillis  and  one  of  the  pe- 
ronei  can  be  brought  forward  to  the  front  of  the  foot  and  given  an  an- 
terior attachment  on  the  tarsus.  In  this  procedure  a  posterior  as  well 
as  an  anterior  incision  is  needed,  and  the  transferred  tendon  is  passed 
subcutaneously  forward  from  the  posterior  to  the  anterior  incision. 

The  operative  reduction  of  calcaneus  or  calcaneo-valg7is  is  not  per- 
manently accomplished  by  simple  shortening  of  the  tendo  Achillis,  be- 


V 


Fig.  392. 


Fig. 


393 


Fig.  392. —Transplantation  of  Ten- 
don.    (Berger  and  Banzet.) 

Fig.  393. — Side  Incisions  in  Tendon  to 
Permit  Elongation  without  Loss  of 
Continuity.    (Berger  and  Banzet.) 


442  ORTHOPEDIC  SURGERY. 

cause,  being  paralyzed,  the  tendon  will  again  stretch  and  the  deformity 
recur.  If  the  posterior  part  of  the  os  calcis  is  set  up  toward  the  ankle, 
a  better  relation  of  the  foot  to  the  leg  is  obtained.  The  operative  pro- 
cedure is  as  follows :  The  side  of  the  os  calcis  is  exposed  by  an  incision 
sufficiently  long  and  an  osteotome  is  used  to  loosen  the  posterior  part 
of  the  OS  calcis  from  the  front  part.  The  line  of  separation  begins 
above,  just  posterior  to  the  astragalus,  and  runs  downward  and  forward 
obliquely.  When  this  part  is  separated  the  heel  is  set  up  by  pressure 
on  the  tuberosity  of  the  os  calcis.  The  tendo  Achillis  is  then  exposed 
and  reefed  until  it  is  tight  with  the  foot  in  its  corrected  position. 

If  an  element  of  valgus  exists  with  the  calcaneus,  some  of  the  ten- 
dons of  the  common  extensor  should  be  cut  and  given  a  periosteal  in- 
sertion into  the  scaphoid  or  cuneiform.  It  may  also  be  advisable  to 
change  the  insertion  of  one  of  the  peronei  muscles  to  the  inner  border 
of  the  foot. 

In  pes  cavns  the  plantar  fascia  is  to  be  tenotomized,  the  foot  forci- 
bly stretched,  with  an  osteotomy  of  the  tarsus  in  extreme  cases.  Oste- 
otomy of  the  OS  calcis  is  also  to  be  considered  in  pronounced  varus  and 
valgus  with  distortion  of  that  bone.  The  proceeding  is  similar  to  that 
in  congenital  club-foot. 

Paralysis  of  the  Exteiisor  Cniris. — This  paralysis  can  be  improved  if 
the  hamstring  muscles  are  sufficiently  strong.  The  tendcTn  of  the  bi- 
ceps (or  a  portion  of  it)  and  the  semimembranosus  are  freed  near  their 
attachments  by  incision  at  both  sides  of  the  leg,  and  are  brought  for- 
ward under  the  skin  and  stitched  securely  into  the  ligamentum  patellae 
close  to  the  patella.  It  is  necessary  that  the  muscles  should  be  freed 
sufficiently  high  up  from  their  attachments  so  that  the  muscles  can  be 
brought  to  the  front  of  the  leg  without  being  curved. 

Transplantation  of  the  sartorius  into  the  conjoined  tendon  of  the 
quadriceps  can  be  performed,  but,  as  the  muscle  is  not  a  strong  one,  as 
much  effective  strength  cannot  be  expected  from  its  transferrence  as 
from  that  of  the  hamstring.  This  procedure  sacrifices  a  portion  of  the 
power  of  flexion  of  the  limb  at  the  knee — a  loss  which  is  compensated 
for  by  the  greater  usefulness  of  the  limb. 

Pai'alysis  of  the  Upper  Extremity. — A  portion  of  the  trapezius  can 
be  transferred  to  the  insertion  of  the  deltoid  in  paralysis  of  the  latter. 
Tendon  transferrence  in  paralysis  of  the  wrist  is  of  value.  The  same 
principles  of  procedure  are  necessary  in  the  upper  as  in  the  lower  ex- 
tremity. 

It  is  almost  needless  to  state  that  suppuration  diminishes  the  pros- 
pect of  benefit  from  tendon  and  muscle  transplantation,  and  the  meas- 
ure should  not  be  undertaken  except  by  an  adept  in  thorough  asepsis. 

After-Treatment. — After  the  operation  the  limb  should  be  protected 
by  sufficient  cotton  padding  and  fixed  in  the  desired  corrected  position 


ANTERIOR   POLIOMYELITIS.  443 

in  a  plaster-of-Paris  bandage,  arranged  so  as  to  allow  the  required  in- 
spection after  dressing.  After  six  weeks  the  plaster  bandage  is  to  be 
followed  by  a  retention  apparatus,  such  as  has  already  been  described, 
and  the  gradually  increasing  use  of  the  limb  allowed,  along  with  mas- 
sage and  passive  exercises  to  develop  the  transferred  muscles  to  their 
new  work. 

Arthrodesis. — Where  the  paralysis  is  total  or  nearly  so  tendon  trans- 
ferrence  is  useless,  and  the  disability  of  the  limb,  except  by  mechanical 
assistance,  would  be  unavoidable  were  it  not  for  the  procedure  of  ar- 
throdeses, which  is  devised  for  the  purpose  of  stiffening  the  flaccid 
joint.  This  is  more  commonly  applied  to  the  ankle-joint  and  is  at- 
tempted by  opening  the  joint  freely  and  exposing  the  astragalus,  which 
should  be  denuded  of  cartilage  on  all  its  articular  surfaces,  as  well  as 
the  lower  end  of  the  tibia  and  fibula.  It  is  necessary  that  the  os  calcis 
should  not  be  free  to  move  under  the  astragalus,  and  the  joint  surfaces 
of  the  calcaneocuboid  articulation  are  also  to  be  denuded  in  very  lax 
joints  to  prevent  a  subsequent  distortion  from  the  loosening  of  that 
joint. 

In  cases  of  severely  relaxed  ankle-joints  it  is  of  use  to  shorten  the 
anterior  or  other  groups  of  muscles,  in  order  to  have  them  serve 
as  stays  to  the  newly  stiffened  joint  in  its  resistance  to  strain. 

Arthrodesis  can  be  employed  in  stiffening  the  knee  and  has  been 
employed  to  fix  the  shoulder  and  hip.  In  the  latter  joint,  however,  the 
operation  has  hitherto  been  of  doubtful  benefit. 

After  operation  the  joint  should  be  fixed  in  a  correct  position  for 
two  months,  after  which  gradually  increasing  use  is  to  be  allowed. 

Nerve-Twisting. — It  is  possible  in  some  cases,  where  very  slight 
power  remains  in  some  muscles  of  a  limb,  to  increase  and  distribute  that 
power  better  by  a  division  and  twisting  of  the  main  nerve  of  the  limb. 

The  nerve  is  dissected  out  and  sutures  are  passed  through  the  sheath 
in  such  a  way  that,  when  they  are  tightened  after  the  nerve  is  cut,  the 
distal  end  is  rotated  on  the  proximal  end  through  one-third  of  a  circle. 
The  nerve  is  cut  after  the  sutures  are  passed,  the  sutures  are  tied,  and 
the  wound  is  closed.  Decided  improvement  in  function  has  been  re- 
ported.' 

Nerve  Transplantation. — It  has  been  demonstrated  experimentally 
by  Spitzy "  that  nerve  impulses  may  be  given  new  directions  by  nerve 
anastomosis;  that  is,  connecting  the  proximal  end  of  one  nerve  with 
the  peripheral  end  of  another  and  transferring  its  motor  impulse. 
Peckham  ^  transplanted  in  two  cases  two  branches  of  the  internal  pop- 
liteal nerve  into  the  external  popliteal ;  in  both  cases  there  was  some 

'Verbal  communication  from  Dr.  W.  S.  Baer,  of  Baltimore. 
-American  Jour.  Orth.  Surgery,  August,  1904. 
'^Providence  Med.  Journal,  January,  1900. 


444  ORTHOPEDIC  SURGERY. 

restoration  of  power  in  the  extensor  muscles.  J.  K.  Young,  of  Phila- 
delphia/ has  since  reported  a  case  of  successful  nerve  transplantation 
in  the  leg. 

The  technique  has  been  elaborated  experimentally  by  Spitzy.- 

Osteotomy  may  be  required  to  correct  severe  flexion  deformity  at 
the  hip,  and  at  the  knee  to  correct  the  knock-knee  and  flexion  at  the 
same  time.  At  the  hip  it  does  not  differ  from  the  ordinary  Gant  oper- 
ation, and  is  necessary  only  in  cases  in  which  division  of  the  soft  parts 
is  not  enough  to  allow  sufficient  extension  of  the  thigh  on  the  pelvis. 

At  the  knee  a  simple  transverse  division  of  the  femur  is  made  just 
above  the  condyles,  allowing  correction  of  both  flexion  and  knock-knee 
at  the  same  time.  These  operations,  of  course,  have  no  effect  upon  the 
paralysis  as  such,  but  merely  serve  to  place  the  limb  in  a  position  suit- 
able for  weight-bearing.  After  operation  mechanical  support  is  usually 
necessary. 

Excision. — In  other  cases  resection  of  joints  is  to  be  considered  on 
account  of  the  extreme  bony  deformity  which  they  present,  as  in  severe 
paralytic  knock-knee,  in  which  a  stiff  knee  rather  than  a  movable  one  is 
desired.  If  the  latter  is  preferable  an  osteotomy  rather  than  excision 
should  be  done,  as  excision  leaves  a  stiff  joint.  The  deformity  of 
knock-knee  or  flexion  at  the  knee  can,  of  course,  be  corrected  by  the 
plane  of  the  bone  section  in  excision. 

^  Am.  Journ.  Orth.  Surg.,  August,  1904. 
-Zeitsch.  f.  orth.  Chin,  xiii. 


CHAPTER    XV. 
SPASTIC   AND    OTHER   PARALYSES. 

Spastic  paralysis. — Congenital. — Acquired. — Symptoms.— Idiocy. — Etiology  of  ac- 
quired spastic  paralysis. — Pathology. — Diagnosis. — Prognosis. — Treatment. — 
Pseudo-hypertrophic  paralysis. — Progressive  muscular  atrophy. — Hereditary 
ataxia.— Obstetrical  paralysis. 

SPASTIC    PARALYSIS. 

The  condition  is  known  under  tlie  following  names :  Spastic  paraly- 
sis, spastic  hemiplegia,  Little's  disease,  spastische  Gliederstarre,  etc. 
The  affection  is  more  common  than  was  formerly  supposed.  At  the 
Children's  Hospital  310  cases  of  cerebral  paralysis  came  under  treat- 
ment, while  987  cases  of  infantile  paralysis  appeared  during  the  same 
period. 

;  Motor  disturbances  in  children  which  are  due  to  cerebral  lesions 
are  manifested  clinically  in  one  of  three  ways:  (i)  As  a  single  hemiple- 
gia; (2)  as  a  diplegia;  (3)  as  a  paraplegia.  Contractures,  choreiform 
movements,  mental  impairment,  aphasia,  epilepsy,  inco-ordination,  etc., 
may  be  the  accompaniments  of  any  one  of  these  forms. 

The  distribution  of  paralysis  in  225  cases  analyzed  by  Peterson  and 
Sachs  was  as  follows:  Right  hemiplegia,  81 ;  left  hemiplegia,  75;  diple- 
gia, 39;  paraplegia,  30.     Total,  225. 

Congenital  Spastic  Paralysis. 

It  is  usually  not  recognized  at  birth,  as  it  consists  of  a  lack  of  mus- 
cular co-ordination  common  in  infancy,  which  persists  in  certain  mus- 
cles during  life.  The  origin  of  it  is  to  be  found  in  cerebral  defects, 
intra-uterine  cerebral  hemorrhage,  and  lack  of  development  of  the 
brain. 

Acquired  Spastic  Paralysis. 

Symptoms. — The  form  most  commonly  seen  is  that  acquired  during 
or  after  labor.  The  onset  may  resemble  very  closely  that  of  infantile 
spinal  paralysis;  it  often  begins  with  an  illness  of  some  sort.  Fre- 
quently paralysis  develops  in  the  course  of  an  infectious  disease,  some- 
times after  an  attack  of  what  seems  to  be  indigestion  or  a  slight 
feverish  attack,  sometimes  after  a  fall  or  a  slight  blow  on  the   head. 

445 


446 


ORTHOPEDIC  SURGERY. 


Commonly  the  onset  is  marked  by  convulsions.  Delirium  or  screaming 
spells  may  accompany  the  onset.  Sometimes,  however,  though  very 
rarely,  the  disease  develops  suddenly  in  perfectly  healthy  children 
without  any  febrile  or  other  disturbance,  or  it  may  develop  insidiously 
without  disturbance  enousrh  to  attract  attention.     From   the  second 


Fig.  394.— Case  of  Right  Hemiple.aria  At- 
tempting to  Walk. 


Fig.  395. 


-Attitude  in   Attempted    Walking, 
Spastic  Paraplegia. 


year,  for  the  first  six  or  seven  years  of  life,  the  liability  ver}'  gradually 
diminishes :  the  number  of  cases,  however,  rises  slightly  at  the  time  of 
the  second  dentition.  In  this  respect  it  offers  a  sharp  contrast  to  in- 
fantile spinal  paralysis. 

When  the  paralysis  is  noticed,  it  is  found  to  be  most  often  hemiple- 
gic  in  distribution.  Monoplegia  is  rare.  The  face  is  paralyzed  in  a 
moderate  proportion  of  all  cases,  and  the  arm  is  always  affected  more 
severely  than  the  leg  and  recovers  more  slowly.  The  facial  paralysis 
ordinarily  is  not  complete  and  does  not  affect  the  muscles  that  close 
the  eyes.  It  disappears  first  of  all  the  paralyses,  and  often  recovery  is 
complete.  Strabismus  is  very  common.  The  paralyzed  side  is  power- 
less, but  sensation  is  generally  unimpaired  ;  coldness  and  vascular  slug- 
gishness are  present  m  some  of  the  severer  cases.     The  reflexes  of  the 


SPASTIC  AND    OTHER   PARALYSES.  447 

affected  side  are  much  increased  from  the  first — a  sign  which  is  of  the 
greatest  assistance  in  diagnosis.  As  in  the  hemiplegia  of  adults,  rigid- 
ity of  the  affected  muscles  comes  on  in  about  seventy-five  per  cent  of 
all  cases  at  a  varying  time  after  the  onset  of  the  paralysis.  The  rigid- 
it)-,  when  present,  is  increased  by  any  attempt  to  use  the  limb ;  it  is 
excited  by  passive  manipulation  and  it  disappears  during  sleep  and 
usually  under  an  anaesthetic.  Post-hemiplegic  movements  follow  in  a 
certain  proportion  of  cases.     Hemianopsia  may  be  present. 

Aphasia  accompanies  probably  a  certain  proportion  of  cases  of  cere- 
bral paralysis,  but  it  is  often  transitory.  It  is  always  motor  aphasia, 
and  may  accompany  either  right  or  left  hemiplegia. 

Mental  enfeeblement,  varying  from  complete  idiocy  to  simple  back- 
wardness, develops  in  a  large  proportion  of  all  cases.  In  the  26  cases- 
in  the  Children's  Hospital  series  '  only  6  had  what  was  classed  as  aver- 
age intelligence,  and  i  of  these  was  aphasic  and  i  stuttered  very  badly. 
Of  the  rest,  7  were  idiotic,  8  feeble-minded,  and  4  very  backward. 
Sachs  found  idiocy  present  in  35  per  cent  of  all  diplegias  and  in  60  per 
cent  of  paraplegias,  while  it  occurred  in  but  13  per  cent  of  hemiplegias. 
Such  chiklren  as  escape  mental  deterioration  in  childhood  often  develop 
psychoses  later  in  life. 

Epileptic  attacks  appear  in  the  paralyzed  limbs  and  thence  become 
generalized  in  one-quarter  to  one-half  of  all  cases  reported.  Ordinarily 
they  come  on  in  two  or  three  years  after  the  paralysis,  but  they  may 
be  delayed,  and  ten  or  even  thirty  years  may  elapse  sometimes;  on  the 
other  hand,  they  may  begin  within  a  few  weeks  of  the  onset. 

The  mind  may,  however,  remain  perfectly  clear  in  spite  of  a  severe 
hemiplegia,  and  no  sign  of  mental  deterioration  may  be  present  in  the 
early  or  the  late  history  of  the  disease.^ 

To  the  later  history  of  the  affection  belong  the  atrophy  and  contrac- 
tions of  the  limbs.  In  hemiplegia  the  affected  side  rarely  recovers  en- 
tirely, and  often  the  growth  of  the  bones  is  retarded.  The  muscular 
atrophy,  as  a  rule,  is  not  so  great  as  in  infantile  spinal  paralysis,  but  in 
certain  cases  the  muscles  waste  very  much.  In  severe  cases  there  is. 
marked  arrest  of  growth  in  the  bones.  In  the  Children's  Hospital 
series  one  case  showed  a  shortening  of  two  inches  in  the  arm  after  the 
paralysis  had  lasted  seventeen  years,  and  three  other  cases  of  four, 
seven,  and  eight  years'  standing  showed  a  shortening  of  one  inch. 
This  points  to  some  trophic  lesion. 

The  permanent  contractions  that  come  on  are  most  noticeable  in 
the  arm,  and  as  a  rule  are  of  one  type  in  the  arm  and  leg.  In  the 
former  the  arm  is  held  close  to  the  side,  the  elbow   is  flexed  strongly 

'  Lovett :  Boston  Med   and  Surg.  Journal,  cxviii.,  641. 

-'  Spiller;  "Spastic  Spinal  Paralysis."  Philadelphia  Med.  Journal,  June  21st, 
1902. 


448 


ORTHOPEDIC  SURGERY. 


and  firmly,  the  hand  is  flexed,  and  the  fingers  are  drawn  into  the  palm, 
usually  embracing  the  thumb.  The  humerus  is  rotated  inward,  and 
outward  rotation  is  resisted  by  muscular  contraction.  Supination  and 
extension  of  the  fingers  are  resisted.  These  contractions  are  very  firm 
and  resisting.  The  leg  in  bad  cases  is  adducted  and  flexed  at  the  hip, 
the  hamstring  muscles  of  the  knee  have  contracted,  and  flexion  of  the 
knee  has  resulted,  and  the  foot  is  in  a  position  of  talipes  equino-varus 
or  simple  equinus.  In  other  cases  only  the  finer  movements  of  the 
hand  may  be  lost,  and  the  leg  movements  may  be  impaired  only  enough 
to  cause  a  bad  limp. 

Post-Paralytic  Disorders  of  Movement. — In  certain  cases  of  hemi- 
plegia, single  and  double,  a  disturbance  of  motion  occurs  at  a  later 
stage,  which  is  spoken  of  under  many  different  names,  such  as  atheto- 
sis and  chorea  spastica;  while  what  is  called  "congenital  chorea  "in 
many  cases  is  the  same  affection. 

Spastic  Condition  of  the  Muscles. — At  times  the  tonic  spasm  of  the 
muscles  becomes  the  most  prominent  feature  of  the  case,  and  there  is 
a  persistent  stiffness  and  constant  spasm  of  the  muscles  of  the  legs  and 


"Fig.  396. — Atrophy  of  the  Hand  in  a  Case  of  Hemiplegia  of  Several  Years'  Duration.    (Knapp.) 

sometimes  of  the  arms;  the  legs  are  straight  and  rigid,  and  the  feet  are 
extended,  and  when  an  attempt  is  made  to  walk  the  child  stands  on 
tiptoe,  and  often  the  spasm  of  the  adductor  muscles  is  so  great  that  the 
legs  are  crossed.  The  walk  is  almost  characteristic — a  clinging  gait, 
in  which  the  feet  are  scraped  along  the  floor  with  much  effort  and 
straining  at  every  step,  if  indeed  the  spasm  is  not  so  great  that  walking 
at  all  is  out  of  the  question. 

In  general  this  affection  is  the  result  of  a  cerebral  lesion  and  a  de- 
scending degeneration  of  the  lateral  columns  of  the  spinal  cord. 

This  grade  of  affection  in  the  majority  of  cases  represents  the  result 


SPASTIC  AND   OTHER  PARALYSES. 


449 


of  a  larger  brain  lesion  than  takes  place  in  hemiplegia.  For  this  rea- 
son, these  children  are  for  the  most  part  feeble-minded  or  idiotic — as 
one  might  reasonably  expect  as  the  result  of  so  extensive  a  brain  lesion 
occurring  at  so  early  an  age. 

However,  one  not  uncommonly  sees  children  of  more  than  average 
intelligence  affected  with  spastic  paraplegia,  so  that  the  existence  of 
spastic  paralysis  is   by  no   means  evi- 
dence of  mental  inferiority. 

Often  these  children  have  strabis- 
mus, a  stupid,  idiotic  face,  the  saliva 
drips  from  the  mouth,  and  the  teeth  de- 
cay very  early.  In  the  milder  cases  the 
difficulty  in  walking  lies  in  the  fact  that 


Fig.  397.- 


■Attitude   Assumed    in    Kitting   by   a 
Feeble-Minded  Child. 


Fig. 


. — Spastic  Paraplegia  in  an 
Adult. 


any  effort  to  use  the  limbs  increases  the  muscular  spasm  and  tends  to 
throw  the  leg  into  the  position  of  extreme  adduction,  with  extension 
of  the  foot  and  generally  slight  flexion  of  the  knees  with  talipes 
equinus.  It  is  often  impossible  to  demonstrate  the  increased  tendon 
reflexes  either  at  the  knee  or  at  the  ankle  on  account  of  the  great 
stiffness  of  the  legs,  because  the  muscles  are  continually  at  their 
maximum  of  contraction.  The  electrical  reaction  in  these  and  in  the 
hemiplegia  cases  is  unchanged. 

In  certain  cases  the  spasm  is  so  great  that  the  patient  is  unable  to 
29 


45 O  ORTHOPEDIC  SURGERY. 

stand  alone.  When  supported,  the  thighs  are  adducted  very  closely 
and  the  toes  pointed  and  crossed. 

The  mental  disability  may  be  manifested  in  the  milder  cases  by  an 
excessive  irritability  and  a  disposition  to  do  mischief  and  perhaps  to 
destroy  playthings  wantonly.  Furious  outbursts  of  temper  are  not 
uncommon. 

It  seems  as  if  spastic  paralysis  of  the  legs  were  occasionally  a  sequel 
of  simple  hemiplegia  coming  on  after  some  years. 

Inco-ordination  or  Idiocy. — This  condition  may  be  the  accompani- 
ment of  cerebral  palsy  or  it  may  be  the  result  of  other  causes. 

The  classification  of  Sachs  is  as  follows : 

1.  Hereditary  idiocy -]  ^,/  ,     ^.  '      , 

■'  '  (^)  developmental. 

I  after  traumatism. 

2.  Acquired  idiocy  -j  after  convulsions. 

I  after  infectious  diseases. 

3.  Myxoedematous  idiocy. 

The  only  excuse  for  its  introduction  here  is  the  very  close  outward 
resemblance  that  these  conditions  present  on  superficial  examination  to 
the  spastic  cases  already  considered;  but  definite  paralysis  and  spastic 
rigidity  of  the  muscles  are  absent,  and  idiocy  obscures  everything.  If 
patients  are  seen  seated,  the  stupid  cross-eyed  look,  the  drooping  head, 


HMH 

^" 

•  1 

^j3P^ 

s  Al 

^ 

^^M^^^K^-^i^^^ 

'  ^jMk 

B 

s 

Fig.  399. — Severe  Infantile  Spastic  Paralysis. 

and  the  drooling  are  exactly  what  is  seen  in  the  severe  mental  enfee- 
blement  of  spastic  paralysis  or  hemiplegia.  But  put  the  child  on  his 
feet  and  the  difference  is  at  once  evident.  Either  his  muscles  are  so 
lax  that  he  will  be  unable  to  bear  his  weight  at  all,  or  he  will  stand 
holding  his  parent's  hands  with  his  feet  wide  apart,  his  knees  bent,  and 


SPASTIC  AND    OTHER   PARALYSES.  451 

his  trunk  leaning  forward.  The  whole  body  sways  to  and  fro  with  an 
oscillating  movement,  and  the  sense  of  equilibrium  seems  almost  want- 
ing; if  he  is  let  alone,  he  walks  in  a  staggering,  uncertain  way,  with 
many  falls.  From  this  the  condition  grades  off  to  a  disability  so  great 
that  the  child  cannot  even  sit  up;  when  it  is  propped  up  the  head  lops 
on  to  one  shoulder,  the  vertebral  column  fails  to  support  the  trunk  and 
bends  to  a  marked  degree,  and  every  muscle  seems  limp  and  useless. 
There  is  no  suspicion  of  muscular  rigidity  or  localized  paralysis. 

Sensory  disturbances  are  not  uncommon,  and  often  a  pin  can  be 
thrust  through  the  skin  without  pain.  The  reflexes  are  sometimes  nor- 
mal a,nd  sometimes  increased,  while  the  legs  are  generally  flabby  and 
cool,  and  the  hands  and  feet  often  undeveloped.  Every  grade  of  the 
condition  is  seen  from  that  described  above  to  complete  helplessness. 

Etiology  of  Spastic  Paralysis. — The  etiology  of  prenatal  cases  of 
, cerebral  palsy  is  obscure.  Such  cases  may  occur  in  neurotic  and  epi- 
leptic families.  Traumatism  to  the  mother  during  her  pregnancy, 
severe  illness  of  the  mother,  severe  fright,  and  hereditary  syphilis  are 
among  the  causes.  The  etiology  of  cases  dating  from  birth  is  better 
formulated.  Asphyxia  at  birth,  prolonged  labors,  and  instrumental  de- 
liveries are  frequent  causes. 

In  cerebral  paralysis  acquired  after  birth  there  are  certain  well-for- 
mulated causes.'  Acute  infectious  diseases  play  their  part,  cases  hav- 
ing occurred  after  measles,  scarlatina,  typhoid  fever,  smallpox,  tonsil- 
litis, pneumonia,  pertussis,  cerebrospinal  meningitis,  gastro-enteritis, 
mumps,  diphtheria,  dysentery,  typhus  fever,  and  syphilis.  Fright  and 
trauma  are  two  other  accepted  causes." 

In  a  large  number  of  cases  the  disease  seems  to  affect  perfectly 
healthy  children  without  any  assignable  cause.  The  indigestion  attacks, 
the  fever,  and  the  convulsions  attending  the  onset  cannot  fairly  be  as- 
signed as  causes.  The  disease  is  about  evenly  divided  between  the 
sexes. 

Pathology. — The  pathological  condition  is  much  the  same  in  hemi- 
plegia, diplegia,  and  paraplegia.  These  conditions  in  general  are  due  to 
embolism  or  hemorrhage,  and  the  resulting  retardation  of  growth  of  the 
affected  portion  of  the  brain,  together  with  the  secondary  changes  in 
the  spinal  cord.  Autopsies  made  later  in  the  disease  show  pathological 
changes  which  are  more  extensive  and  less  definite  in  their  character. 
Wasting  and  sclerosis  of  a  greater  or  less  part  of  the  brain  and  the  con- 

'  Phila.  Med.  News,  18S7,  ii. — Parvin  :  American  Journ.  Med.  Sci  ,  1S75. — 
Sinkler:  Med.  News,  1S85,  vol.  i.— McNutt:  Am.  Jour,  of  Obst  ,  1SS5.— Parrot : 
"  Clinique  des  Nouveau-nes,"  Paris,  1877. 

-Obstet.  Trans.,  London,  vol.  xxvi. ;  Boston  Med.  and  Surg.  Journal,  June 
2Sth,  1888.— Osier:  Phila.  Med.  News,  July  14th,  18S8.— Abercrombie  :  St.  Barth. 
Hosp.  Rep.,  xvi.,  p.  35,  and  Brit.  Med.  Journ.,  June  iSth,  1887. 


45- 


ORTHOFEDIC  SURGERY 


dition  known  as  porencephalus  are  what  one  finds  in  these  later  cases. 
These  seem  to  be  the  late  results  of  the  destructive  change  mentioned 
above,  which  have  occurred  in  a  growing  brain  and  have  retarded  its 
growth  and  have  produced  an  extensive  scar  formation  in  the  place  of 
cerebral  tissue.  Porencephalus  occurs  as  a  loss  of  substance  in  the 
fomi  of  cavities  or  cysts. 

The  pathology  of  the  condition '  is  a  lesion  of  the  motor  tract  of  the 
brain  with  consequent  atrophy  and  retarded  development  of  the  affected 
portion,  and  descending  degeneration  of  the  pyramidal  tracts  and  lateral 


Fig.  400. — Distorted  Brain  in  Case  of  Infantile  Spastic  Paralj'sis. 


columns  of  the  cord.  From  the  extensive  atrophy  found  in  young  chil- 
dren at  autopsy,  it  seems  that  unquestionably  sometimes  the  disease 
originates  in  defective  development  of  the  nervous  centres,  especially 
the  pyramidal  tracts,  rather  than  in  an  acute  cerebral  hemorrhage  or 
embolism. 

The  theory  that  the  condition  was  due  to  a  poliencephalitis  similar 

'  E.  H.  Bradford  :  Am.  Joum.  of  Orth.  Surgery,  vol.  i..  p.  375. 


SPASTIC  AND    OTHER   PARALYSES.  453 

to  poliomyelitis  has  not  received  confinnation  nor  the  support  of  mod- 
ern neurologists. 

To  enter  upon  a  discussion  of  the  pathological  condition  in  the  cases 
of  inco-ordination  spoken  of  above  would  be  to  introduce  the  very  ex- 
tensive subject  of  the  pathology  of  idiocy.' 

Diagnosis. — Spastic  paraplegia  is  characterized  by  tonic  contraction 
of  the  muscles  which  yields  to  steady  resistance,  except  in  the  advanced 
stages  where  fibrous  changes  have  taken  place.  The  galvanic  reaction 
is  normal.  At  times  the  muscular  rigidity  is  so  excessive  that  the  ex- 
aggerated knee-jerk  and  ankle  clonus  cannot  be  obtained.  In  estimat- 
ing the  child's  mental  condition,  very  little  weight  can  be  attached  to 
the  parents'  account  of  the  patient's  capacity. 

The  differentiation  of  cerebral  paralysis  and  infantile  spinal  paraly- 
sis has  been  dealt  with. 

Obstetrical  paralysis  might  be  mistaken  for  a  cerebral  lesion,  but  a 
careful  examination  would  determine  the  paralysis  to  be  limited  to  the 
distribution  of  some  especial  nerve  or  group  of  nerves.  It  occurs  in 
the  distribution  of  the  facial  nerve  after  the  use  of  the  forceps,  but  it 
occurs  as  a  rule  in  the  shoulder  in  consequence  of  the  stretching  of  the 
nerve  trunks  in  the  manual  extraction  of  the  child's  body. 

Cerebral  tinnors  may  cause  the  symptoms  of  hemiplegia,  and  a  diag- 
nosis of  this  condition  from  the  lesions  generally  causing  paralysis 
would  ordinarily  be  impossible.  Tumors  of  the  pons  or  cerebellum 
would  cause  symptoms  of  bilateral  rigidity  (spastic  paraplegia)  if  the}'- 
compressed  the  motor  tracts. 

Pseudo-h\"pertrophic  paralysis,  the  pseudo-paralysis  of  rickets,  s}"phi- 
lis  of  the  spinal  cord,  and  hereditary  spastic  paralysis  are  possible 
sources  of  an  error  of  diagnosis  in  obscure  cases.  Certain  cases  of 
chorea  prove  on  investigation  to  have  their  origin  in  a  slight  cerebral 
paralysis.     The  same  may  be  said  of  epilepsy. 

Prognosis. — The  prognosis  in  these  cases  should  be  most  guarded, 
and  is  dependent  upon  the  extent  of  the  central  lesion,  not  always  easily 
recognized.  When  epilepsy  or  idiocy  is  present  little  benefit  can  be 
expected  from  surgical  treatment.  The  spastic  muscular  condition  is 
to  be  regarded  as  a  difficulty  in  addition  to  the  epilepsv  or  idiocy 
which  especially  needs  treatment.  When  no  mental  impairment 
is  present  much  benefit  can  be  expected  from  suitable  surgical  treat- 
ment. 

In  formulating  the  prognosis  it  is  to  be  remembered  that  epilepsy 
develops  in  about  half  of  the  cases. 

^  Osier:  Med.  News,  Phila..  August  nth.  iSSS.  p.  143. — Landouzy  and  Sire- 
dey :  Rev.  de  Med..  1S85. — Jendrassik  and  Marie:  Arch,  fiir  Phys.,  1SS5.— Cow- 
ers and  Handford :  Brit.  Med.  Journal.  1SS7.  i..  1098.— Seibert :  Arch,  of  Pe- 
diatrics, March,  1SS8,  16S. 


454 


ORTHOPEDIC  SURGERY. 


Treatment. — In  spastic  paralysis  it  is  at  times  possible  to  accomplish 
much  by  muscular  training  and  exercise.  The  muscles  which  are  most 
strongly  contracted  are  the  thigh  adductors  and  the  calf  muscles. 
Such  a  patient  should  be  given  exercises  calculated  to  develop  the  ab- 
ductor muscles  and  the  dorsal  flexors  of  the  foot,  which  by  increased 
power  will  in  a  measure  counterbalance  the  muscles  which  are  too  pow- 
erful. The  patient  should  lie  on  the  back  on  a  hard  table,  and  should 
separate  the  legs  as  far  as  possible  at  first  without  being  touched,  and 

then  against  slight  resistance. 
The  legs  in  the  extended  posi- 
tion should  be  rotated  outward, 
while  the  heels  are  kept  to- 
gether. In  walking  the  patient 
should  be  cautioned  to  go  very 
slowly,  to  lift  each  foot  well  off 
of  the  ground,  and  to  turn  out 
the  toes  with  much  care.  In 
connection  with  massage  and 
rubbing,  this  method  of  treat- 
ment is  capable  of  accomplishing 
a  decided  change  in  the  method 
of  walking,  and,  while  the  walk 
may  be  stiff  and  unsteady,  it  has 
lost  the  characteristic  scraping 
and  dragging  of  the  spastic  gait. 
Such  patients  walk  with  much 
less  fatigue  than  before  and  feel 
much  more  steady  upon  their 
feet. 

The  disappearance  of  the 
aphasia  is  aided  by  systematic 
training  and  it  always  proves 
more  tractable  than  in  the  adult. 
Apparatus  is  suited  to  the 
treatment  of  the  milder  deformities  only.  Talipes  equino-varus  of  a 
mild  degree  may  be  temporarily  corrected  by  a  proper  appliance  (Chap- 
ter XXI.,  37).  The  muscles  furnish  sufficient  support  to  the  affected 
limbs,  but,  owing  to  the  increased  reflex  excitability  and  to  imperfect 
motor  impulses,  the  muscles  are  in  a  state  of  spasm  and  of  useless- 
ness  from  the  distorted  position.  In  general  the  deformities  are  to 
be  treated  as  in  infantile  paralysis.  The  deformity,  however,  returns 
immediately  on  removal  of  the  appliance,  so  that,  apart  from  the  tem- 
porary rectification,  apparatus  is  of  little  advantage  in  cerebral  par- 
alysis.    Retentive  apparatus,  however,  is  of  use  in  retaining  the  limbs 


Fig.  401.  — Spastic  Paralj^sis  before  Operation. 


SPASTIC  AND   OTHER  PARALYSES. 


455 


in  proper  position  after  operation  (Chapter  XXI.,  ^5).  Post-hemi- 
plegic  movements  are  at  times  relieved  by  placing  the  member  at  rest 
for  some  weeks  or  months  under  restraint. 

Operative  Treatment. —  Tenotomy,  Myotomy,  Fasciotoiny. — Clini- 
cal evidence  has  proved  that  tenotomy,  especially  of  the  tendo  Achillis, 
in  this  class  is  of  great  benefit  in  suitable  cases,  not  only  in  improved 
walking,  but  sometimes  in  improvement  of  the  general  condition  and 
diminution  of  the  general  irritability,  from  the  benefit  of  increased  ac- 


FiG.  402. — Spastic  Paralysis  after  Operation. 

tivity.  The  orthopedic  surgeon  will  meet  a  certain  number  of  cases  of 
this  class  with  pronounced  equinus  deformit}'  of  one  or  both  feet.  Lo- 
comotion is  difficult  for  the  reason  that  it  is  impossible  for  the  patient 
to  bear  the  weight  upon  the  whole  sole  of  the  foot.  This  increased 
difficulty  is  sometimes  suificient  to  deter  the  patient  from  efforts  at  lo- 
comotion and  always  adds  to  the  unsteadiness  of  gait.     If  tenotomy  of 


456  ORTHOPEDIC  SURGERY. 

the  tendo  Achillis  is  done,  the  contraction  ceases,  and  though  the 
strength  of  the  muscle  is  not  lost  in  a  number  of  cases  which  have 
been  watched  by  the  writers  for  several  years,  there  is  little  tendency 
to  a  reappearance  of  the  equinus  deformity/ 

In  instances  of  this  sort  a  practical  cure  may  be  gained  by  tenotomy. 
This  treatment  is  especially  suited  to  those  cases  in  which  there  is  lit- 
tle or  no  mental  disturbance. 

Division  of  the  hamstring  tendons  by  open  incision  should  be  done 
when  they  are  suffiicently  contracted  to  prevent  the  full  extension  of 
the  knee.  This  operation  is  preferable  to  subcutaneous  tenotomy  be- 
cause it  offers  a  better  chance  to  divide  contracted  tissues  other  than 
tendons. 

In  the  severer  cases  with  adductor  spasm  division  of  the  adductor 
tendons  is  also  of  benefit,  as  the  adductor  spasm  often  causes  the  knees 
to  knock  together  in  walking  and  is  a  serious  obstacle  in  progression, 
and  even  the  weakening  of  the  muscles  spasmodically  contracted  by 
removal  of  a  portion  of  the  muscular  bellies  is  often  of  use.  Gibney  ^ 
has  removed  the  tensor  vaginae  femoris  with  benefit  to  correct  the 
inversion  of  the  limb  not  infrequently  met.  In  many  instances,  how- 
ever, if  the  intermuscular  septa  and  the  intermuscular  fasciae  are 
thoroughly  divided  in  the  spasmodically  contracted  muscular  area,  the 
remaining  portion  of  the  muscle  can  be  overstretched. 

After-Treatment.  —  After  the  operation  the  limb  is  to  be  fixed 
in  an  overcorrected  position  by  means  of  plaster-of-Paris  bandages  or 
retentive  appliances  for  several  weeks.  This  is  to  be  followed  by 
muscle  training,  gradually  increasing  exercises,  with  limbs  held  by 
ambulatory  retention  appliance  (similar,  as  a  rule,  to  what  are  to  be 
used  in  infantile  paralysis)  until  the  proper  muscular  balance  has  been 
established,  when  appliances  are  to  be  discarded. 

It  is  to  be  remembered  that  the  affection  is  not  strictly  a  paralysis, 
but  a  disability  from  imperfect  muscular  co-ordination,  increased  by 
muscular  contraction  in  certain  muscles.  The  treatment  consists  in 
not  only  restoring  the  muscular  balance,  but  in  muscle  training  to  re- 
establish the  proper  muscular  co-ordination.  Care  is  necessary  during 
the  process  of  muscle  training  with  apparatus  not  to  overstretch  the 
divided  tendons,  as,  for  example,  after  division  of  the  tendo  Achillis,  as 
locomotion  with  stiffened  knees,  necessary  in  the  earlier  stages  of  after- 
treatment  of  a  contracted  limb,  brings  unusual  strain  upon  the  tendo 
Achillis.  It  is  advisable,  therefore,  in  tenotomy  of  this  tendon  (where 
hamstring  contraction  exists),  to  perform  plastic  tenotomy.  This  is 
done  by  dividing  half  of  the  tendon  at  different  levels  and  on  different 

^  O.  Vulpius :  "Die  Sehneniiberpflanzung."  etc.,  Leipsic,  1902,  p.  197  (with 
bibliography). 

-American  Journ.  of  Orth.  Surgery,  vol.  ii.,  No.  i. 


SPASTIC  AND    OTHER   PARALYSES. 


457 


sides,  and  by  stretching  the  tendon,  elongating  it  without  leaving  a  gap 
entirely  across. 

Tendon  transferrence  has  been  recommended  in  this  affection, 
especially  of  the  hamstrings  forward,  to  reinforce  the  lengthened  ex- 
tensor curis  by  a  procedure  similar  to  what  is  employed  in  poliomyelitis. 
This  would  avoid  the  need  of  muscle  training,  with,  however,  a  loss  of 
the  muscular  balance  which  is  always  desirable.  The  procedure  should 
be  reserved  for  the  more  severe  cases. 

Tendon  transferrence,  however,  is  of  great  advantage  in  the  spastic 
contraction  of  the  forearm. 

Arm  and  Ha7id. — The  pronator  radii  teres  may  be  converted  into  a 
supinator,^  and  the  carpal  flexors  may  be  converted  into  carpal  exten- 
sors." In  the  first  operation  an  incision,  two  or  three  inches  long,  is 
made  in  the  middle  of  the  front  of  the  forearm.  The  upper  and  corner 
borders  of  the  pronator  are  cleared  and  the  tendon  with  its  periosteal 
attachment  is  freed  from  the  radius.  The  tendon  is  then  passed  through 
the  interosseus  membrane  close  to  the 
radius  and  the  tendon  reinserted  on 
the  outer  side  of  the  radius,  if  possible 
at  the  site  of  its  former  insertion ;  if 
not,  at  a  new  roughened  place  on  the 
radius. 

In  the  other  operation "  the  flexor 
carpi  ulnaris  is  divided  just  above  the 
annular  ligament  and  inserted  into  the 
tendon  of  the  extensor  ulnaris,  and 
the  flexor  carpi  radialis  divided  at  the 
same  level  and  attached  to  the  radial 
extensor. 

Operations  upon  the  Brain. — 
It  is  natural  that  exploratory  trephin- 
ing should  be  attempted  in  cerebral 
paral^'sis  when  the  lesion  can  be  well 
localized.  Little  benefit,  however,  has 
as    yet    followed    this    procedure    in 

spastic  paralysis,  for  the  reason  that  the  degenerative  changes  following 
the  congenital  defect  are  such  as  are  not  relieved  by  operative  inter- 
ference. It  is  possible,  if  the  operation  could  be  performed  at  an  early 
stage  shortly  after  birth,  that  benefit  might  result. 

There  are  certain  motor  disturbances  affecting  children  which  come 
under  the  notice  of  the  orthopedic  surgeon  so  frec|uently  that  a  brief 

'A.  H.  Tubby:  Brit.  Med.  Journ..  September  7th,  1901. 

-Robert  Jones:  Tubby  and  Jones,  "Surgery  of  Paralyses."  London.  1903,  p. 


Fig.  403.— Tran.splantation  of  the  Pro- 
nator Radii  Teres  in  Spastic  Paralysis 
of  the  Arm. 


458  ORTHOPEDIC  SURGERY. 

mention  of  their  characteristics  deserves  a  place  here.     These  affec- 
tions are: 

I.  Pseudo-hvpertrophic  muscular  paralysis.     Progressive  muscular 
atrophy. 

II.  Hereditarv  locomotor  ataxia. 


I.  PSEUDO-HYPERTROPHIC  MUSCULAR  PARALYSIS. 

Definition. — Pseudo-hypertrophic  muscular  paralysis  is  an  affection 
of  the  muscular  system  characterized  by  a  diminution  or  loss  of  the 
functional  energ}'  of  certain  muscles  and  an  abnormal  increase  in  their 
size,  which,  together  with  diminution  in  the  size  of  other  muscles,  is 
pathognomonic.  The  affection  is  also  known  as  muscular  pseudo-hy- 
pertroph\",  lipomatous  muscular  atrophy,  diffuse  muscular  lipomatosis, 
mvopachynsis  lipomatosa  (Uhde) ;  Paralysie  myosclerosique,  paralysie 
musculaire  pseudo-hypertrophique.  Modern  classification  places  the 
affection  among  the  progressive  muscular  atrophies. 

Etiology. — The  etiology  of  the  affection  is  not  known.  The  disease 
develops  usually  during  childhood,  but  in  exceptional  instances  its  ap- 
pearance is  delayed  until  the  age  of  eighteen  or  twenty  years.  It 
affects  males  more  commonly  than  females  in  about  the  proportion  of 
four  or  five  males  to  one  female.  The  disease  is  more  apt  to  occur  in 
familv  groups  than  in  isolated  cases,  and  the  hereditary  element  is 
marked. 

Pathology. — The  pathological  condition  consists  in  the  overgrowth 
of  the  connective  tissue  in  the  muscles  and  the  wasting  of  the  muscular 
substance  proper,  "while  a  deposit  of  fat  takes  place  to  a  greater  or  less 
extent.  No  constant  or  characteristic  pathological  condition  is  found 
in  the  spinal  cord,  although  various  changes  have  been  described,  and 
the  condition  is  at  present  still  regarded  as  a  primary  affection. 

Symptoms. — The  first  symptoms  to  attract  attention  to  the  child's 
condition  are  muscular  feebleness  and  peculiarity  of  gait.  These  gener- 
ally precede  any  noticeable  enlargement  of  the  muscles.  Such  children 
tire  \Qx\  easily  in  walking  and  they  have  especial  difficulty  in  going  up 
and  down  stairs.  They  fall  often  and  in  rising  from  the  ground  they 
adopt  a  procedure  which  is  one  of  the  most  characteristic  features  of 
the  disease.  Inasmuch  as  on  account  of  muscular  weakness  they  can- 
not straighten  the  back  or  extend  the  knees  without  assistance,  they 
rise  from  the  ground  in  the  manner  shown  in  Figs.  406,  407,  using  the 
muscles  of  the  arms  to  accomplish  what  the  leg  and  back  muscles 
cannot  do. 

These  children  tend  to  walk  with  legs  apart,  and  at  times  an  awk- 
ward gait  and  a  tendency  to  fall  are  for  a  long  period  the  only  symp- 
toms of  the  affection. 


SPASTIC  AND   OTHER  PARALYSES. 


459 


Such  patients  learn  to  walk  late  and  depend  much  m  their  progress 
upon  the  assistance  afforded  by  the  furniture,  upon  which  they  lean 
heavily.  In  kneeling  on  the  hands  and  knees  at  times  there  may  be 
noticed  a  characteristic  saddle-shaped  depression  of  the  back,  which  is 
due  to  the  weakness  of  the  erector  spinas  muscles.  This  is  not  an  early 
accompaniment  of  the  disease,  but  is  a  characteristic  of  the  late  stage 
when  much  lordosis  is  also  present 
in  standing. 

In  walking  these  children  throw 
the  centre  of  gravity  of  the  body 
well  over  each  leg  in  turn  as  it  sup- 
ports the  body-weight.  In  this  way 
they  save  muscular  effort.  The 
result   is  a  waddle   more   or  less 


Fig.  404.— Kj'phosis  in  Pseudo-h^-pertro- 
phic  Paralj-sis. 


Fig.  405. — Case  of  Pseudo-hypertro- 
phic  Muscular  Paralysis. 


marked.  They  may  stand  with  marked  lordosis  of  the  lumbar  spine, 
chiefly  due  to  a  weakness  of  the  lumbar  muscles.  The  lordosis  disap- 
pears when  the  patient  sits  down  and  a  bowing  backward  of  the  whole 
vertebral  column  takes  its  place. 

Mental  enfeeblement  is  associated  with  the  disease  in  many  cases. 
The  enlargement  of  the  muscles  is  usually  most  marked  in  the  calves 
of  the  legs.  On  this  account  the  parents  generally  feel  no  anxiety 
because  the  child  walks  late  or  feebly,  inasmuch  as  the  development  of 
the  legs  seems  so  remarkably  good. 


460 


ORTHOPEDIC  SURGERY. 


Fig.  406.— Series  of  Photographs  Showing  Method  of  Getting 
up  from  the  Ground  in  Pseudo-hypertrophic  Muscular 
Paralysis.    (Curschmann.) 


The  affected  mus- 
cles are  hard  and  re- 
sistant to  the  touch, 
but  at  times  the  sen- 
sation in  handling 
them  is  like  that  of  a 
fatty  tumor. 

Atrophy  of  some 
of  the  muscles  of  the 
upper  extremity  is  apt 
to  be  present.  The 
scapular  muscles,  the 
serrati,  the  latissimus 
dorsi,  and  the  pecto- 
ralis  major  are  often 
wasted. 

Talipes  equinus 
and  flexion  of  the 
knees  and  hips  may 
occur  from  muscular 
contraction.  Lateral 
curvature  of  the  spine 
may  follow,  and  at 
other  times  a  perma- 
nent flexion  of  the 
spine  occurs  from 
w^eakness  of  the  erec- 
tor spinae  muscles,  and 
the  child  sits  bowed 
forward.  But  these 
deformities  mark  only 
the  late  stage  of  the 
affection,  which  is 
more  often  character- 
ized by  a  helplessness 
more  or  less  complete. 
Neither  the  re- 
flexes nor  the  elec- 
trical reactions  are 
modified  in  any  degree 
until  the  muscles  have 
reached  a  marked 
stage  of  atrophy. 
Then  they  are  dimin- 


SPASTIC  AND    OTHER  PARALYSES. 


461 


ished  in  proportion  to 
the  muscular  wasting, 
and  finally  they  are 
lost.  The  reaction  of 
degeneration  is  not 
present.  Very  often 
the  skin  over  the  af- 
fected limb  is  mottled 
and  subject  to  vascu- 
lar changes,  indicat- 
ing some  vasomotor 
disturbance. 

Diagnosis.  —  In 
well-defined  cases  the 
affection  in  its  later 
stages  is  not  likely  to 
be  mistaken  for  any- 
thing else.  The  pe- 
culiar gait  with  the 
feet  wide  apart  and  a 
reckless  disregard  of 
falls,  the  characteris- 
tic method  of  rising 
from  the  floor,  the 
age  of  the  patient,  and 
the  progressive  char- 
acter of  the  disease,  all 
suggest  this  affection. 
If  examination  shows 
enlargement  of  the 
calf  muscles  and  nor- 
mal or  diminished  re- 
flexes, the  diagnosis 
may  be  considered  as 
established.  Yet  of 
even  greater  diagnos- 
tic importance  than 
the  enlargement  of 
the  calf  muscles  is 
the  combination  of  en- 
largement of  the  in- 
fraspinatus and  wast- 
ing of  the  latissimus 
dorsi    and    pectoralis 


Fig.  407.— Series  of  Photographs  Showing  Method  of  Getting 
up  from  the  Ground  in  Pseudo-hypertrophic  Muscular 
Paralysis.     (Curschmann.) 


462  ORTHOPEDIC  SURGERY. 

major  muscles — a  state  of  affairs  to  which  great  diagnostic  importance 
is  to  be  attached. 

The  gait  in  early  hypertrophic  paralysis,  and  that  in  idiocy,  spastic 
paralysis,  in  the  paralysis  of  rickets  and  Pott's  disease,  and  in  simple 
weakness  have  very  much  in  common. 

Prognosis. — The  prognosis  is  as  unfavorable  as  possible.  Recovery 
is  all  but  unknown/  and  arrest  of  the  disease  is  rare." 

The  course  of  the  disease  is  essentially  chronic.  The  earliest  stage 
is  made  manifest  by  muscular  feebleness,  and  passes  on  to  a  stage  in 
which  hypertrophy  of  the  muscles  becomes  evident.  This  stage  is  pro- 
gressive and  at  the  end  of  it  the  pseudo-hypertrophy  reaches  its  maxi- 
mum and  the  disease  becomes  stationary  and  remains  so  for  two  or 
three  or  perhaps  several  years.  Then  comes  a  time  of  increasing  fee- 
bleness and  extension  of  the  paralysis.  The  muscles  waste  and  the 
power  of  movement  is  lost  in  the  legs  and  arms.  In  this  deplorable 
condition  the  patient  may  live  on  until  death  comes  from  increasing 
exhaustion  or  some  intercurrent  disease. 

Treatment  is  practically  without  benefit,  and  there  is  no  reason  to 
believe  that  drugs  have  any  effect  in  retarding  its  progress.  Electric- 
ity, massage,  and  gymnastics  are  sometimes  of  benefit  in  connection 
with  other  treatment. 

Tenotomy  is  of  use  as  soon  as  the  heels  are  drawn  up.  Often  walk- 
ing may  become  impossible,  chiefly  on  that  account,  and  division  of  the 
tendo  Achillis  on  both  sides  may  restore  for  a  time  the  power  of  walk- 
ing; also  tenotomy  of  the  hamstring  tendons  at  the  knee  may  be  indi- 
cated in  severe  cases. 

PROGRESSIVE    MUSCULAR   ATROPHY. 

Progressive  muscular  atrophy  is  an  affection  characterized  by  a 
wasting  of  the  voluntary  muscles,  and  a  consequent  diminution  in  their 
power,  which  pursues  a  chronic  course  and  attacks  successively  indi- 
vidual muscles  and  groups  of  muscles. 

Etiology. — In  muscular  atrophy  as  it  occurs  in  children,  the  only 
cause  assignable  is  a  congenital  tendency,  often  inherited.  But  at 
times  isolated  cases  are  met,  and  in  adults  other  causes  are  to  be  taken 
into  account. 

Males  are  more  often  affected  than  females,  and  the  time  of  onset 
of  the  disease  is  most  variable ;  it  may  begin  as  early  in  life  as  at  the  age 
of  three  years  or  as  late  as  sixty,  but  its  development  in  advanced  life 
is  rare. 

'  Duchenne  :  Arch.  gen.  de  r^Ied.,  1S6S.  i..  pp.  5  and  6. 

-Donkin:  "Note  on  a  Case  of  Pseudo-hypertrophic  Paralysis.  Recoverj'." 
Brit.  ?vled.  Journal,  April  15th,  1882. 


SPASTIC  AND    OTHER   PARALYSES.  463 

Progressive  muscular  atrophy  has,  since  the  days  of  Aran  and  Du- 
chenne,  been  subdivided  into  different  types. 

1.  In  the  Aran-Duchenne  type  the  atrophy  begins  oftenest  in  the 
small  muscles  of  the  hand,  spreads  to  the  forearm  and  perhaps  the 
shoulders  and  back.  It  may  begin  in  the  muscles  of  the  thighs.  The 
atrophied  muscles  show  fibrillary  contractions,  and  the  reaction  of  de- 
generation is  present. 

The  affection  has  a  pathology  and  is  of  spinal  origin.  The  changes 
found  are  a  sclerotic  and  pigmentary  atrophy  of  the  ganglion  cells  of 
the  anterior  cornua,  an  inflammatory  condition  of  the  neuroglia,  and 
cellular  proliferation.    The  anterior  nerve  roots  are  affected  secondarily. 

2.  The  hereditary  form  is  of  the  same  general  type  as  the  preceding. 
It  is  very  unusual  and  may  occur  in  more  than  one  member  of  a  family. 

3.  The  peroneal  form  or  leg  type  of  progressive  muscular  atrophy 
affects  in  most  cases  the  lower  extremities.  The  extensor  muscles  of 
the  toes  are  first  affected,  then  the  small  muscles  of  the  feet,  and 
finally  the  entire  leg.  Talipes  equinus  or  equino-varus  is  a  common 
result.  The  development  of  double  club-foot  with  progressive  wast- 
ing of  the  lower  extremities  is  very  suggestive  of  this  type  of  the  af- 
fection.    It  may  affect  the  upper  extremities  first  and  then  the  lower. 

Sensory  changes  are  generally  present.  The  reflexes  in  the  lower 
extremities  may  be  diminished  or  lost  if  the  disease  is  sufficiently  ad- 
vanced. The  electrical  reactions,  as  a  rule,  are  altered  both  quantita- 
tively and  qualitatively.  Cases  of  club-foot  occurring  in  this  type  may 
be  successfully  operated  on.' 

The  changes  in  the  muscles  consist  in  atrophy  of  the  fibres,  a  loss 
of  transverse  striation,  and  a  proliferation  of  the  nuclei.  Degenera- 
tions of  the  nerves  are  present,  but  changes  of  importance  in  the  spinal 
cord  have  not  been  established. 

The  two  remaining  types  along  with  pseudo-hypertrophic  paralysis 
are  to  be  classed  as  primary  myopathies  or  primary  muscular  dystro- 
phies, in  that  they  are  not  associated  with  demonstrable  lesions  \\\  the 
spinal  cord. 

4.  Erb's  type.  The  juvenile  form  of  progressive  muscular  atrophy 
is  very  rare  and  is  characterized  by  progressive  wasting  of  certain 
groups  of  muscles.  These  are  the  muscles  of  the  shoulder  girdle,  the 
upper  arm,  the  pelvic  girdle,  the  thigh,  and  the  back.  The  forearm 
and  leg  muscles  remain,  for  a  long  time  at  least,  intact.  There  are  no 
fibrillary  contractions,  no  reaction  of  degeneration,  and  no  sensory  dis- 
turbances. 

5.  The  Landouzy-Dejerine  type  or  the  facio-scapulo-humeral  variety 
occurs  at  times  in  children.  The  muscles  of  the  face  are  first  affected 
and  the  atrophy  spreads  to  the  shoulder  and  arm  muscles.     In  excep- 

'  Sachs:  Loc.  cit.,  p.  413. 


464 


ORTHOPEDIC  SURGERY. 


tional  cases  this  type  may  begin  in  the  arms  or  legs.     The  reaction  of 
degeneration  and  fibrillary  twitching  are  never  present. 

Treatment. — The  medical  treatment  of  all  these  affections  is  hope- 
less. When  muscular  contractions  occur  tendons  should  be  cut  and 
deformities  rectified.  Rest  to  the  atrophied  muscles,  massage,  and 
electricity  are  useful. 

HEREDITARY   ATAXIA. 

Hereditary  ataxia  deserves  mention  as  a  serious  motor  disorder 
which  is  sometimes  met  in  children.  It  is  dependent  upon  a  family 
predisposition,  but  is  not  often  directly  inherited,  but  more  commonly 
appears  in  several  members  of  one  generation.  Hence  the  name  of 
family  ataxia.  It  is  also  known  as  Friedreich's  disease.  Other  names 
are  hereditary  ataxic  paraplegia  and  degenerative  ataxia.  The  cases 
are  rare. 

Etiology. — Aside  from  the  influence  of  a  congenital  tendency  the 
cause  of  the  disease  is  as  yet  unknown.'  The  disease  develops  most 
often  early  in  life.     The  sexes  seem  equally  liable  to  the  affection. 

Pathology. — In  examining  sections  of  the  cord  in  these  cases,  a  de- 
generation of  the  lateral  columns,  with  a  more  intense  and  plainly 
marked  sclerosis  of  the  posterior  columns,  is  found.  This  is  similar  to 
the  lesion  of  locomotor  ataxia. 

Symptoms. — The  symptoms  resemble  very  closely  those  of  locomo- 
tor ataxia,  except  that  the  lightning  pains  of  the  early  stage  and  crises 


Fig.  408.— Deformity  of  the  Feet  in  a  Case  of  Friedreich's  Disease.     Hyperextension  of  the 
toes  and  club-foot,     (^larie.) 

are  not  so  marked  as  in  the  latter  affection.  Hereditary  ataxia,  more- 
over, involves  the  upper  extremities  more  severely  and  earlier  in  the 
course  of  the  affection. 

The  patient  notices  a  feeling  of  weakness  and  uncertainty  in  walk- 
ing, and  soon  it  becomes  apparent  to  others  that  the  motions  of  the 
legs  are  not  properly  co-ordinated.  The  feet  are  placed  wide  apart  in 
standing,  and  in  walking  the  gait  is  practically  that  of  locomotor  ataxia. 

'Gowers:  Vol.  i.,  p.  3S0.— Shattuck :  Bost.  Med.  and  Surg.  Journal,  vol. 
cxviii.,  7,  p.  168.— Smith:  Boston  Med.  and  Surg.  Joum.,  October  15th,  1885. 


SPASTIC  AND    OTHER   PARALYSES.  465 

The  movements  of  the  hands  become  irregular  and  inco-ordinate,  and  a 
jerky  irregularity  develops  in  the  movements  of  the  head  and  neck,  so 
much  so  that  it  may  assume  the  aspect  of  an  irregular  tremor.  Speech 
may  also  be  impaired. 

The  knee-jerk  disappears,  but  the  plantar  reflex  remains.  Sensa- 
tion is  affected  in  var)'ing  degrees  in  different  cases,  and  trophic 
disturbances  of  the  skin  are  not  present.  As  a  rule  the  sphincter  mus- 
cles are  not  affected.  Nystagmus  is  often  present;  the  Argyll-Robert- 
son pupil  is  absent. 

Deformities  are  apt  to  come  on  in  the  later  stages  of  the  disease. 
Lateral  curvature  may  be  present ;  talipes  equinus  or  equino-varus  and 
permanent  flexion  of  the  knee  are  likely  to  occur. 

Diagnosis. — In  a  clearly  marked  case  the  walk  is  characteristic  and 
resembles  that  of  ordinary  locomotor  ataxia.  The  deep  reflexes  are 
diminished  or  absent  and  there  is  a  certain  amount  of  disturbance  of 
sensation;  the  electrical  reactions  are  normal.  Isolated  cases  occur 
rarely,  and  a  history  of  some  such  affection  in  other  members  of  the 
same  family  aids  very  much  in  the  diagnosis. 

Prognosis The  disease  is  essentially  progressive,  and  the  progno- 
sis is  bad  in  proportion  to  the  rapidity  of  progress.  Death  usually 
occurs  from  intercurrent  affections,  but  sometimes  the  disease  lasts  for 
thirty  years  or  more  and  does  not  seem  to  have  shortened  life.  It  is 
not  likely  to  cause  death  inside  of  ten  or  twelve  years  at  the  least,  and 
nothing  can  be  expected  from  treatment. 

Treatment. — ^The  treatment  should  be  similar  to  that  in  common 
use  in  locomotor  ataxia.  The  gen>«ral  hygiene  of  the  patient  should  be 
most  carefully  regulated,  and  skilful  massage  sometimes  accomplishes 
much  in  keeping  up  the  nutrition  of  the  muscles  and  thus  diminishing 
the  patient's  disability.  Electricity  in  the  same  way  is  of  use,  but  it 
is  distinctly  second  in  importance  to  proper  massage.  Deformities 
should  be  corrected  by  tenotomy,  etc.,  as  they  occur. 

Among  similar  affections  are  the  cerebellai'  type  of  hereditary  ataxia 
described  by  Marie,  differing  chiefly  in  having  exaggerated  reflexes  and 
ocular  symptoms  in  addition  to  those  described  above. 

OBSTETRICAL   PARALYSIS. 

Obstetrical  paralysis  of  the  shoulder  is  an  affection  which  is  fairly 
common  and  often  results  in  a  disabled  arm.  It  occurs  most  often 
after  difficult  labors  when  traction  is  made  upon  the  head  in  head  pres- 
entations, or  upon  the  trunk  when  the  head  is  delivered  last.  It  may 
occur,  however,  after  normal  labors.' 

The  injury  appears  to  be  due  to  injury  to  the  two  upper  roots  of  the 

'Boston  Med.  and  Surg   Journal,  1S92. 
30 


466  ORTHOPEDIC  SURGERY. 

brachial  plexus.  It  has  been  found  experimentally  that  the  two  upper 
roots  give  way  first  when  traction  is  made,  becoming  very  tense  when 
the  shoulder  is  pulled  down,  while  the  three  lower  roots  remain  lax 
under  the  same  conditions/  The  paralysis  is  of  Erb's  type  and  the 
nerves  involved  are  the  circumflex,  suprascapular,  musculo-cutaneous, 
and  musculo-spiral. 

The  condition  is  made  manifest  immediately  after  birth  by  an  inabil- 
ity to  use  one  arm  ;  it  hangs  powerless  at  the  side,  with  the  palm  turned 
backward,  and  often  the  fingers  are  flexed  tightly.  If  the  arm  is  lifted 
from  the  side  it  falls  lifelessly  back  into  place,  and  although  movement 
of  the  fingers  is  generally  present,  it  is  impossible  to  use  the  arm  to  any 
extent  on  account  of  the  paralysis  of  the  shoulder  muscles. 

The  p'ogiwsis  in  the  severer  cases  is  not  good  as  to  recovery. 

The  ireatincnt  should  consist  in  the  use  of  a  sling  or  supporting 
bandage  at  first  to  prevent  stretching  of  the  joint  capsule  and  muscles. 
Later  massage  and  electricity  are  likely  to  be  of  use  in  lighter  cases. 
The  muscles  should  not  be  allowed  to  acquire  a  permanent  contraction, 
but  should  be  kept  lax  by  daily  manipulations  of  the  joint.  External 
rotation  and  supination  are  the  most  difficult  motions  to  preserve. 

In  cases  with  contraction,  myotomy  of  the  pectoralis  major  muscle 
followed  by  retention  of  the  arm  in  a  position  to  prevent  contraction  of 
the  scar,  is  of  use. 

When  the  paralysis  affects  only  certain  muscles,  as  is  not  infre- 
quently the  case,  operative  measures,  referred  to  in  the  chapter  on 
"Spastic  Deformities,"  viz.,  muscle  transferrence,  will  be  of  assistance. 
Portions  of  the  trapezius  can  be  transferred  to  the  deltoid,  and  other 
muscular  transferrence  can  be  performed  in  the  forearm  if  any  strong 
muscles  remain. 

If  the  biceps  is  paralyzed  and  no  triceps  can  be  utilized,  the  arm  can 
be  made  more  useful  by  a  procedure  suggested  by  Jones,  of  Liverpool, 
viz.,  a  flap  plastic  operation  in  the  bend  of  the  elbow,  the  skin  and  re- 
sulting scar  tissue  serving  to  hold  the  arm  in  a  slightly  flexed  position, 
which  is  more  useful  than  a  straight  one.  Arthrodesis  can  be  per- 
formed for  the  same  purpose  at  the  elbow. 

'J.  S.  Stone:  Boston  Med.  and  Surg.  Journ.,  1899. 


CHAPTE^'XVI. 
FUNCTIONAL   AFFECTIONS   OF    THE   JOINTS. 

Definition. — Etiology. — Occurrence. —  Symptoms.  — Spine.  — Hip. — Knee. — Ankle. 
—  Diagnosis. — Prognosis. — Treatment. 

DEFIiSriTION: 

Functional  disorders  of  this  class  are  also  termed  hysterical  and 
neuromimetic. 

The  affections  of  this  class  most  often  involve  the  spine,  hip,  knee, 
and  ankle,  although  the  other  joints  can  hardly  be  considered  exempt. 

These  disorders  are  probably  dependent  upon  a  disturbed  nervous 
condition,  perhaps  due  to  a  disordered  blood  supply,  brought  about  by 
nervous  exhaustion  from  overgrowth,  from  disease,  nerve  strain,  or 
from  trauma.  They  are  here  termed  functional,  because  there  is  no 
evidence,  clinical  or  pathological,  of  organic  disease.  Ordinarily  these 
disorders  are  seen  in  persons  of  an  excitable,  emotional  temperament, 
but  exceptionally  the  most  aggravated  type  of  functional  affections  may 
be  seen  in  persons  of  calm  and  composed  demeanor  manifesting  no  ex- 
aggeration in  statement  or  manner.  .        '  ■" 

ETIOLOGY   AND    OCCURRENCE. 

A  study  of  the  etiology  of  this  class  is  disappointing.  As  a  predis- 
posing influence,  an  emotional  temperament,  which  enters  largely  into 
the  exaggerated  statement  of  all  subjective  symptoms,  must  be  consid- 
ered in  all  cases.  The  influence  of  home  training  and  discipline  in  the 
development  of  this  temperament  is  important,  as  well  as  is  heredity. 
Persons  broken  down  in  health  by  suffering  or  chronic  disease  become 
naturally  in  time  incapable  of  bearing  pain,  and  the  statement  of  such 
patients  is  exaggerated  and  the  endurance  lessened. 

Trauma  is  a  frequent  exciting  cause.  In  certain  cases  the  pain 
caused  by  a  synovitis,  for  instance,  seems  to  be  perpetuated  after  its 
legitimate  cause  has  disappeared.  This  is  due  to  the  patient's  abnor- 
mal sensitiveness  and  self-concentration.  Such  sensations  are  to  be 
classed  as  "habit  pains." 

Again,  slight  sources  of  peripheral  irritation,  too  slight  to  be  an 
inconvenience  to  normal  persons,  may  be  a  cause  of  severe  symptoms 
in  neurasthenics.     Among  such  causes  may  be  mentioned  a  short  leg 

467 


468  ORTHOPEDIC  SURGERY. 

or  a  weakened  foot  of  slight  degree,  some  degree  of  thickening  of  the 
synovial  fringes  in  the  knee,  etc. 

This  condition  of  hypersensitiveness  is  sometimes  to  be  seen  in 
young  girls  about  the  time  of  puberty,  and  in  elderly  women  at  the  time 
of  the  menopause,  rarely  in  young  children.  Wom.en  in  young  and 
middle  adult  life  are  the  most  frequent  sufferers.  How  far  sexual  irri- 
tation enters  into  these  cases  as  a  causative  influence  cannot  be  said 
with  certainty,  but  in  some  cases  it  appears  to  be  one  of  the  disturbing 
factors  which  make  up  the  disease.  The  statement  cannot  be  too 
strongly  made  that,  although  these  affections  are  seen  mostly  in  young 
women  at  or  after  puberty,  it  must  not  be  overlooked  that  they  occa- 
sionally occur  in  young  children,  in  boys,  and  also  in  men.  Why  a  dis- 
turbance of  the  nervous  centres  should  result  in  the  manifestation  of  a 
group  of  symptoms  so  closely  resembling  those  of  serious  joint  disease 
is  but  one  of  the  many  unexplained  phases  of  this  disorder.  The  same 
may  be  said  of  the  direction  of  these  symptoms  to  any  particular  joint; 
except  that  traumatism  is  in  many  cases  the  cause  which  determines 
the  concentration  of  the  attention  upon  some  one  joint. 

SYMPTOMS. 

These  affections  may  begin  gradually  or  they  may  be  seen  following 
accident.  Again  they  may  be  the  outcome  of  a  protracted  convales- 
cence from  some  joint  injury.  The  symptoms  presented  are  usually 
much  exaggerated  and  out  of  proportion  to  the  local  signs.  There  is 
usually  a  condition  of  hyperaesthesia,  especially  of  the  skin,  which 
manifests  itself  most  clearly  when  any  manipulation  of  the  affected 
part  is  attempted.  Although  this  is  a  very  important  factor  in  the  de- 
termination of  this  class  of  affections,  the  absence  of  this  hyperaesthesia 
must  not  be  taken  as  sufficient  evidence  to  exclude  the  disease.  An- 
other characteristic  feature  of  these  disorders  is  the  fact  that  the 
objective  signs  vary  from  time  to  time.  The  stigmata  of  hysteria 
accompany  many  of  these  cases  and  when  present  are  of  great  diagnostic 
importance. 

Organic  and  functional  disease  are  frequently  associated.  A  young 
woman  with  some  joint  affection  of  a  mild  character  will  sometimes  so 
exaggerate  and  emphasize  her  symptoms  that  the  case  may  appear  to 
be  of  the  most  acute  sort,  but  careful  examination  will  perhaps  show 
that  the  disease  is  convalescent  and  that  the  real  condition  is  very  favor- 
able. This  can  be  detected  only  by  a  careful  examination  showing 
that  the  muscular  stiffness  varies  much  with  the  attention  of  the  pa- 
tient and  that  much  pain  is  attributed  to  the  slightest  manipulation 
which  can  easily  be  performed  without  suffering  or  muscular  spasm 
when  the  attention  of  the  patient  is  diverted,  while  the  muscular  rigid- 


FUNCTIONAL  AFFECTIONS   OF   THE  JOINTS.      469 

ity  of  chronic  joint  disease  is  a  constant  and  not  a  variable  resistance 
to  passive  manipulation. 

Atrophy  may  be  considerable,  but  it  is  not  more  than  can  be  ac- 
counted for  by  disuse. 

Distortions  of  the  affected  limbs  have  nothing  characteristic  about 
them,  except  that  they  may  or  may  not  follow  the  malpositions  of  the 
limb  which  occur  in  real  joint  disease.  The  hysterical  knee-joint  is 
often  flexed,  and  the  hip  may  be  flexed  and  perhaps  adducted  or  ab- 
ducted. 

In  short,  the  symptoms  of  functional  joint  disease  have  one  distinc- 
tive characteristic,  they  are  chiefly  subjective,  and  objective  signs  of 
structural  trouble  are  absent  or  nQt  prominent.  A  familiarity  with  the 
objective  signs  of  disease  of  the  various  joints  is  of  course  necessary^  in 
making  the  diagnosis  of  functional  troubles,  and  the  foregoing  chapters 
have  dealt  with  those  objective  signs. 

Symptoms  often  associated  with  functional  disorders  are  ovarian 
tenderness  and  pain,  baso-occipital  headache,  a  feeling  of  suffocation  as 
if  a  lump  were  lodged  in  the  throat,  and  symptoms  of  this  class. 

The  association  of  uterine  disorders  is  common,  and  also  another 
frequent  accompaniment  is  found  in  the  presence  of  errors  of  refraction 
in  the  eyes. 

The  surface  temperature  may  be  increased,  local  sweating  may  oc- 
cur, and  neurologists  describe  some  swelling  as  an  accompaniment  of 
certain  cases  of  functional  disorder  of  the  joints. 

The  correction  of  all  sources  of  peripheral  irritation  is  of  course  a 
matter  of  much  importance. 

Spine. 

The  condition  in  this  location  is  also  described  under  the  names  of 
irritable  spine,  hysterical  spine,  spinal  irritation,  functional  affection  of 
the  spine,  weakness  of  the  spine,  neuromimesis,  etc'  The  affection  may 
occur  spontaneously  or  most  often  as  the  result  of  some  trauma,  either 
mild  or  severe.  It  appears  as  a  sensitive  and  painful  condition  of  the 
spine,  manifested  by  sensitiveness  most  often  over  the  spinous  processes 
of  the  vertebrae,  pain  in  motion  and  manipulation ;  and  in  most  of  the 
cases  is  associated  with  a  certain  amount  of  general  neurasthenia. 

Pain  and  tenderness  are  frequently  found  at  the  base  of  the  neck, 
between  the  shoulders,  in  the  lower  dorsal  region,  or  at  the  end  of  the 
spine.  This  pain  is  usually  subacute,  it  is  aggravated  by  fatigue,  and 
it  may  be  accompanied  by  much  hyperassthesia,  which  is  usually  local- 
ized in  a  comparatively  small  area  where  there  is  a  complaint  of  a  burn- 
ing sensation,  while  no  curvature  or  projection  can  be  seen  on  inspec- 

'Friedberg:  Schmidt's  Jahrb.,  1897.— Bruns'  Beitr.,  xi.,  1894.— Willard  and 
Spiller :  "  Concussion  of  tlie  Spinal  Cord."     N.  Y.  Med.  Jour.,  March  6th,  1897. 


470  ORTHOPEDIC  SURGERY. 

tion  of  the  back.  In  the  extreme  cases,  patients  are  unable  to  bear  any 
weight  upon  the  spine  in  sitting  or  standing,  and  they  present  the 
symptoms  that  suggest  a  hyperaesthesia  of  the  hgaments  or  of  the  fas- 
ciae of  the  back  muscles.  Ordinarily  the  patients  are  able  to  go  about 
freely,  but  suffer  great  pain,  especially  when  their  attention  is  turned 
to  the  subject  of  themselves.  In  a  few  instances  of  the  severest  sort 
the  back  is  held  stiffly,  and  any  conscious  attempt  at  bending  is  avoided 
by  the  patient;  but  unconsciously,  when  the  patient's  attention  is  di- 
rected in  another  way,  the  back  will  be  seen  to  move  with  comparative 
freedom. 

A  gait  which  is  very  similar  to  that  of  Pott's  disease  may  be  pres- 
ent, and  also  rigidity  of  the  back  in  rising  or  stooping.  As  in  that 
affection  continued  standing  and  walking  may  cause  pain,  the  patient  is 
very  sensitive  to  any  jar  and  may  be  relieved  from  discomfort  in  the 
recumbent  position. 

A  careful  examination  of  the  patient  usually  shows  that  the  symp- 
toms of  stiffness  are  more  from  an  apprehension  of  possible  pain  of 
movement  than  from  the  unconscious  muscular  spasm  seen  in  the  acute 
stages  of  early  Pott's  disease.  Pain  on  movement,  moreover,  is  usually 
much  greater  than  is  seen  in  early  Pott's  disease. 

Some  deviation  from  the  normal  attitude  in  standing  is  seen  in  most 
cases.'  This  may  be  a  slight  lateral  deviation  of  the  spine  due  to  a 
short  leg.  It  may  be  a  rounded  back  from  lack  of  muscular  support, 
or  it  may  be  a  position  of  lordosis  and  leaning  back  in  an  effort  to 
balance.  Such  patients  generally  are  poorly  developed  muscularly. 
Whatever  defects  exist  should  be  corrected. 

Certain  cases  of  backache  of  this  type  result  from  flat-foot  or  con- 
tracted foot.     An  examination  of  the  feet  should  always  be  made. 

Sprains  of  the  vertebral  column  occur  at  times  after  falls.  Stiffness 
and  pain  may  reach  a  considerable  degree  and  render  the  diagnosis 
from  Pott's  disease  impossible  for  a  time.  In  the  cervical  region  wry- 
neck may  be  present  from  muscular  spasm.  The  pain  may  be  very 
severe.  This  condition  of  sprain  may  persist  for  months,  and  in  neu- 
rasthenic persons  may  merge  into  the  so-called  hysterical  spine. 

PIip. 

The  symptoms  which  may  present  themselves  under  these  condi- 
tions at  the  hip-joint  may  resemble  hip  disease  in  many  particulars. 
There  is  often  complaint  of  a  severe  pain  in  the  limb,  and  any  attempt 
to  move  the  hip  elicits  expression  of  pain.  There  may  be  an  absence 
of  atrophy,  and  the  pain  is  more  likely  to  be  localized  at  the  hip  than  at 
the  knee,  which  is  the  reverse  of  what  happens  in  true  hip  disease. 

^  Lovett :  "The  Neurasthenic  Spine."  Am.  Medicine,  November  30th,  1901  ; 
N.  Y.  Med.  Journal,  May  30th,  1903. 


FUNCTIONAL  AFFECTIONS   OF   THE  JOINTS.      4/1 


Unconscious  movements  at  the  hip-joint  may  be  made  more  freely 
than  in  the  painful  stages  of  hip  disease.  In  some  instances  marked 
fixation  at  the  hip-joint  may  constantly  be  present,  but  usually  the 
stiffness  in  examination  of  the  hip  is  great,  but  unconscious  movements 
at  the  hip  as  in  stooping  are  freer.  The  stiffness  is  more  the  stiffness 
of  apprehension  than  the  limited  mo- 
tion of  early  disease  of  the  joint.  The 
affection  in  children  is  not  common, 
but  by  no  means  exceptional.  The  de- 
formity may  be  marked  and  persistent, 
recurring  quickly  after  reduction. 

Knee. 

Functional  disease  of  the  knee- 
joints  often  simulates  either  chronic 
synovitis  or  ostitis.  Pain  and  tender- 
ness may  be  present,  creaking  is  noted 
as  an  occasional  symptom  in  func- 
tional affections,  and  at  times  there 
seems  to  be  present  an  increase  of 
surface  temperature.  More  commonly 
the  surface  temperature  of  the  af- 
fected side  is  reduced.  The  knee  may 
be  flexed,  but  during  sleep  that  posi- 
tion may  be  involuntarily  abandoned 
or  the  leg  can  be  easily  straightened, 
offering  but  little  resistance.  Con- 
traction of  the  knee  is  often  absent. 
A  moderate  degree  of  muscular  atro- 
phy is  present,  especially  if,  as  is  usu- 
ally the  case,  the  knee  has  been  tightly 
bandaged  for  some  time. 

In   rare   instances   some    swelling 
of    the    periarticular    tissues    around 
the  knee  is  observed  in  this  class  of  cases.     The  swelling  is  transitory 
and  does  not  involve  the  joint  proper. 

Nowhere  does  the  diagnosis  present  greater  difficulty  than  at  the 
knee,  where  traumatism  may  loosen  the  semilunar  cartilages  to  a  slight 
degree  or  do  some  similar  injury.  The  diagnosis  of  functional  disease 
can  be  made  only  after  the  careful  exclusion  of  all  organic  pathological 
conditions  in  both  knee  and  foot.  As  our  knowlege  of  abnormal  con- 
ditions in  the  knee-joint  becomes  more  exact  fewer  cases  are  classed  as 
functional. 


Fig.  409. — Attitude  in  Walking  in  a  Case 
of  Hysterical  Affection  of  the  Joints 
of  the  Leg  in  a  Girl  of  Thirteen. 


472  ORTHOPEDIC  SURGERY. 


Ankle. 


A  functional  disturbance  in  the  ankle  is  not  infrequent.  It  is  most 
commonly  met  as  a  result  of  sprains  which  have  been  treated  for  too 
long  a  time  by  rest  and  fixation.  A  condition  of  muscular  weakness, 
enfeebled  circulation,  and  apprehension  at  slight  pain  ensues,  and  no 
attempt  at  the  proper  means  of  securing  recovery  is  made,  for  the  rea- 
son that  the  first  attempt  to  use  the  disabled  joint  is  painful  and  pain 
is  regarded  as  a  symptom  indicative  of  inflammation. 

In  functional  disease  of  the  ankle  an  attitude  similar  to  talipes  varus 
or  of  flat-foot  may  be  seen.  The  distorted  attitude  in  both  the  knee 
and  the  ankle  may  be  so  constantly  assumed  as  to  cause  a  contraction 
of  the  hamstrings  or  tendo  Achillis. 

At  the  ankle  most  cases  of  functional  affection  are  either  the  out- 
come of  trauma  or  are  associated  with  some  abnormality  of  the  foot. 

The  functional  affections  of  the  other  joints  present  no  points 
worthy  of  especial  mention. 

DIAGNOSIS. 

The  symptoms  are  often  those  of  organic  joint  disease,  but  the 
groups  of  objective  physical  signs  are  deficient  and  inconsistent  with 
one  another.  The  objective  signs  vary  and  are  not  so  severe  as  the 
symptoms  would  lead  one  to  expect.  Pain  is  the  prominent  feature, 
and  muscular  rigidity  and  similar  symptoms  are  of  varying  severity, 
according  to  the  concentration  of  the  patient's  attention.  The  pres- 
ence of  superficial  hyperaesthesia  and  of  signs  characteristic  of  hysteria 
with  an  emotional  temperament  are  facts  which  should  excite  attention. 

In  examining  patients  in  whom  a  functional  affection  is  suspected, 
much  information  can  be  gained  by  watching  the  movements  of  the 
patient  in  getting  out  of  bed,  moving  in  bed,  etc.  The  limbs  or  back 
should  be  bared,  and  the  unaided  movements  watched.  Those  suffer- 
ing from  organic  disease  of  the  hip  or  spine  show  a  constant  stiffness 
or  attempt  to  guard  or  protect  the  affected  limb,  which  is  not  displayed 
to  so  marked  a  degree  in  purely  functional  affections. 

The  diagnosis  to  be  of  value  must  in  practically  all  cases  be  made 
by  a  process  of  exclusion.  Again  it  must  be  remembered  that  func- 
tional and  organic  disease  may  exist  in  the  same  joint,  that  is,  legiti- 
mate symptoms  may  be  so  exaggerated  as  to  constitute  a  functional 
affection. 

X-ray  examinations  are  of  assistance,  as  they  show  the  absence  of 
organic  change  in  the  bone  structures  which  would  be  present  in  tuber- 
culous disease  of  a  prolonged  or  acute  course. 


FUNCTIONAL  AFFECTIONS   OF   THE  JOINTS.      473 

PROGNOSIS. 

If  left  to  itself,  a  true  functional  affection  of  the  spine  or  joints  may 
improve  gradually  without  special  treatment,  or  it  may  remain  un- 
changed until  the  joint  function  becomes  really  impaired  by  the  con- 
tinued inaction.  In  some  cases  a  sudden  and  profound  mental  impres- 
sion may  prove  stronger  than  the  idea  of  local  disease  and  a  cure  is 
effected.  It  is  this  that  the  surgeon  strives  to  accomplish  in  certain 
cases,  it  is  this  that  may  be  brought  about  by  faith  cure  or  charlatanry, 
and  rational  treatment  of  a  similar  sort  can  likewise  win  excellent  re- 
sults if  properly  carried  out. 

The  age  of  the  patient  and  the  duration  of  the  affection  are  impor- 
tant in  determining  the  outlook.  The  older  the  patient  and  the  longer 
the  course  of  the  disease  the  less  favorable  is  the  prognosis. 

The  existence  of  some  peripheral  source  of  irritation  renders  the 
immediate  prognosis  perhaps  more  favorable. 

TREATMENT. 

In  few  disorders  is  a  routine  treatment  of  less  use  than  in  functional 
affections  of  the  joints  or  spine.  Especially  important,  from  the  out- 
set to  the  end  of  the  treatment,  is  an  established  diagnosis,  on  which 
the  surgeon  can  rely.  To  attempt  to  follow  out  a  treatment  which 
shall  be  suitable  to  either  functional  or  organic  disease  is  fatal  to  a  suc- 
cessful issue.  Temporizing  on  the  part  of  the  physician  at  once  makes 
successful  treatment  almost  impossible.  A  definite  plan  of  treatment 
must  be  formulated  and  adhered  to. 

The  disorder  usually  manifests  itself  as  a  disability  of  a  limb,  the 
object  of  treatment  being  to  overcome  the  disability.  Various  meth- 
ods will  be  needed  to  effect  this. 

It  is  first  necessary  that  the  patient  be  brought  into  as  nearly  nor- 
mal a  general  condition  as  possible.  The  improvement  of  the  local 
condition  is  then  to  be  considered  and  estimated,  and  finally  the  patient 
is  to  be  trained  to  regain  the  use  of  the  disabled  limb  or  spine.  In 
cases  in  which  the  spine  is  involved,  rest  to  the  back  must  be  secured 
by  recumbency  for  part  of  the  day.  Elaboration  of  treatment  is  desir- 
able in  many  cases  and  a  rigid  adherence  to  a  careful  and  continuous 
routine  of  exercises,  feeding,  and  medication  must  be  insisted  upon. 
This  class  of  cases  cannot  be  successfully  treated  unless  due  attention 
is  given  to  regulating  and  improving  diet  and  general  condition,  and 
correcting  sleeplessness. 

For  the  treatment  of  the  local  condition,  the  physician  has  to  decide 
between  the  necessity  of  correcting  any  existing  distortion  or  local  im- 
proper conditions  of  circulation  or  muscular  weakness  of  the  limb  or 


474  ORTHOPEDIC  SURGERY. 

back,  and  the  danger  of  increasing  the  expectant  attention  of  the  pa- 
tient by  too  great  attention  to  the  local  condition.  It  is  for  this  reason 
that  counter-irritation  and  the  cautery  are  to  be  avoided.  It  is  essen- 
tial that  the  local  condition  should  not  be  made  light  of  by  the  surgeon, 
and  the  reality  of  the  symptoms  must  be  accepted  and  the  disability 
recognized.  A  probable  hypothesis  explaining  the  condition  must  be 
assumed,  and  treatment  based  upon  this  should  be  carefully  and  con- 
sistently carried  out.  Any  statement  that  the  affection  is  a  trivial 
nervous  disorder  or  that  it  can  be  overcome  by  exercise  of  the  will  is 
in  most  cases  an  error. 

An  important  part  of  local  treatment  is  the  improvement  of  the  cir- 
culation in  the  part  affected,  and  strengthening  of  the  surrounding 
muscles.  This  can  be  done  by  massage,  local  hot-air  baths,  electricity, 
and  gymnastics. 

In  general  the  beneficial  effect  of  the  local  measures  adopted  must 
be  insisted  on,  and  by  a  graduated  amount  of  enforced  exercise  pro- 
gressively increased,  the  patient  may  be  surprised  into  finding  herself 
daily  doing  more  without  feeling  more  pain.  Sometimes  it  may  be  only 
practicable  to  make  the  patient  take  two  steps  a  day,  but  the  advance 
to  three  and  four  steps  is  an  important  gain.  It  may  be  repeated  that 
without  a  certainty  on  the  physician's  part  that  he  is  dealing  with  a 
functional  affection,  and  without  a  rigid  adherence  to  his  formulated 
plan  of  treatment,  success  is  not  often  to  be  obtained. 

Great  benefit  can  be  obtained  by  graduated  exercises  in  this  class 
of  cases.  Another  useful  way  of  accomplishing  this  result  is  by  means 
of  mechanical  passive  and  active  exercises  according  to  the  method 
introduced  by  Zander. 

Appliances  as  a  rule  should  be  avoided,  but  in  some  cases  they  are 
temporarily  needed  to  enable  the  patient  to  go  about  more  freely  when 
there  is  marked  muscular  weakness.  They  should  be  discarded  as 
soon  as  is  practicable.  In  the  spine  the  tempered  steel  uprights  (Chap- 
ter XXI.,  32)  spoken  of  in  connection  with  round  shoulders  are  of  use 
temporarily  in  aiding  in  the  maintenance  of  the  upright  position. 

In  functional  affections  of  the  hip,  knee,  and  ankle  it  is  sometimes 
necessary  to  employ  crutches  in  order  to  give  locomotion  and  exercise. 
Crutches  should  be  used  sparingly,  and  only  temporarily,  inasmuch 
as  there  is  danger  of  the  patient  becoming  habituated  to  them. 

When  contractions  and  malposition  of  the  limbs  are  present,  these 
should  be  corrected  either  by  operation  or  by  mechanical  means.  Op- 
erative measures  are  usually  simple,  as  under  an  anaesthetic  the  limb 
can  be  pulled  readily  into  normal  position,  while  only  in  severe  cases  is 
tenotomy  of  the  resisting  muscles  needed.  Appliances  will  probably 
be  required  to  retain  the  limb  in  the  corrected  position. 

Light  cases  of  functional  affection  of  the  hip  will  be  best  treated  at 


FUNCTIONAL  AFFECTIONS   OF   THE  JOINTS.      475 

first  by  the  use  of  crutches  and  the  elevated  shoe  to  che  well  foot,  aided 
by  gymnastic  exercises  for  the  limb  of  such  a  character  as  the  patient 
can  endure.  The  elevated  shoe  should  be  lowered  and  removed  gradu- 
ally, and  in  the  same  way  crutches  should  be  shortened  and  replaced 
by  a  cane,  and  finally  all  support  discarded  by  gradual  stages.  The 
use  of  a  hip  splint  will  not  often  be  found  advantageous  on  account  of 
its  weight.  Traction  by  weight  and  pulley  is  rarely  needed,  but  is 
sometimes  advisable. 

Much  judgment  is  required  to  determine  what  cases  of  functional 
affection  of  the  hip,  knee,  and  ankle  joints  are  to  be  treated  by  rest,  by 
protection  of  the  limb,  or  by  use. 

Rest  in  bed  is  to  be  avoided  unless  the  patient  is  in  a  marked  neu- 
rasthenic condition  needing  quiet,  but  confinement  to  bed  is  generally 
unavoidable  during  the  correction  of  deformity. 

Whatever  the  methods  of  treatment  to  be  instituted,  it  is  absolutely 
essential  that  the  physician  should  h^ve  complete  control  of  the  man- 
agement of  the  case  without  interference  of  friends  or  relations.  Often 
it  is  therefore  necessary  to  take  the  patient  away  from  home  for  the 
time  being.  In  many  cases  the  home  influence  is  a  most  important 
factor  in  inducing  and  keeping  up  this  condition. 

It  is  of  importance  for  the  physician  to  obtain  the  patient's  co-oper- 
ation in  the  treatment  prescribed.  It  is  a  mistake  to  belittle  the  symp- 
toms or  to  treat  them  as  imaginary.  They  are  not  only  real  to  the 
patient,  but  in  fact  are  probably  the  result  of  some  unrecognizable  cen- 
tral vasomotor  disturbance  causing  functional  disability,  and  not  of  the 
■patient's  fancy.  The  disability  is  usually  increased  by  the  patient's 
apprehension  or  self-will.  These  are  not  overcome  by  contradicting  the 
patient's  statements.  As  the  local  symptoms  of  hyperaemia,  anaemia, 
congestion,  atrophy,  and  muscular  weakness  are  diminished  by  rest, 
support,  careful  exercise,  application  of  heat  or  cold,  hot  air,  vibratory 
massage,  manipulation,  or  whatever  measure  may  be  employed,  the  use 
of  the  limb  should  be  gradually  increased  with  each  day's  task  prescribed. 
The  gradual  gain,  even  if  slight,  brings  encouragement  to  the  patient. 

Cases  vary  in  difficulty  and  often  tax  the  physician's  efforts  to  the  ut- 
most in  meeting  the  varying  symptoms,  but  in  many  instances  such  efforts 
are  essential  as  necessary  to  save  the  patient  from  hopeless  invalidism. 

In  cases  in  which  functional  symptoms  are  superadded  to  an  organic 
lesion,  much  skill  and  judgment  are  required  in  treatment. 

In  all  these  varieties  of  functional  affections,  the  principle  of  treat- 
ment is  the  same — temporarily  to  protect  the  affected  part  from  strain 
and  painful  use,  to  improve  the  circulation  and  increase  the  muscular 
strength,  and  as  the  condition  improves  to  train  the  patient  to  the 
gradual  resumption  of  the  normal  use  of  the  limb.  A  combination  of 
muscular  training  with  mind  cure  constitutes  the  treatment. 


CHAPTER    XVII. 
UNILATERAL   ATROPHY   AND    HYPERTROPHY. 

Cases  of  unilateral  difference  in  the  growth  of  the  body  are  of  prac- 
tical interest. 

Hunt/  of  Philadelphia,  in  1879,  made  observations  which  led  him  to 
state  that  bilateral  symmetry  as  to  the  length  of  the  lower  limbs  was 
exceptional.  Since  then  several  observers  have  corroborated  the  views 
of  Hunt.  Dr.  Cox  ^  measured  the  lower  limbs  in  fifty-four  healthy  per- 
sons, and  in  only  six  were  the  limbs  of  the  same  length.  There  was  no 
uniformity  with  regard  to  which  side  was  the  longer.  The  variation  in 
length  was  from  one-eighth  to  seven-eighths  of  an  inch.  Wight  ^  gives 
the  measurements  of  sixty  persons,  and  concludes  "that  the  greater 
number  of  limbs,  comparing  the  limbs  of  the  same  person,  show  a  dif- 
ference in  length.  About  one  person  in  every  five  has  limbs  of  the 
same  length."  The  difference  is  usually  from  one-eighth  of  an  inch  to 
an  inch.  In  one  case  the  difference  was  as  great  as  one  and  three- 
eighths  inches. 

Callender  *  measured  forty  individuals,  and  found  the  limbs  of  equal 
length  in  all  but  two,  in  whom  the  variation  was  slight.  He  used  a 
simple  tape.  All  the  persons  measured  happened  to  be  Englishmen. 
Roberts  '  and  Dwight "  have  attempted  to  settle  the  question  by  obser- 
vation on  the  bones  of  skeletons.  Roberts  found  asymmetry  the  rule 
in  femora  and  tibiae  in  eight  skeletons.  Dwight  reported  measurements 
in  eleven  skeletons;  in  five  the  femora  were  equal;  in  one  case  the 
difference  was  three-quarters  of  an  inch.  Tibiae  were  equal  in  only 
two  cases.  In  some  cases  the  longer  femora  and  tibiae  were  on  the 
same  side,  and  in  some  cases  on  different  sides. 

Dr.  J.  Garson,'  of  London,  published  the  results  of  the  measure- 
ments of  seventy  skeletons.  The  lower  limbs  were  equal,  he  says,  in 
only  ten  per  cent. 

'Am.  Journal  Med.  Sciences,  January,  1879. 
-Am.  Journal  Med.  Sciences,  April,  1875. 
^Archives  Clin.  Surg.,  vol.  i..  No.  8,  February,  1877. 
■*  St.  Bartholomew's  Hospital  Reports,  vol.  xiv.,  1878,  p.  187. 
5  Philadelphia  Med.  Times,  August  3d,  1S78. 
''Mass.  Med.  Soc.  Communications,  1878,  p.  175. 

'Journal  of  Anat.  and  Phys.,  vol.  xiii.,  p.  502,  1879.  Nature,  January  26th, 
1SS4. 

476 


UNILATERAL   ATROPHY  AND   HYPERTROPHY.     477 

Morton  '  has  made  many  measurements  and  found  that  among  513 
boys  292  presented  inequality  in  the  length  of  the  lower  limbs  varying 
from  one-eighth  of  an  inch  to  one  inch  and  five-eighths.  In  241  there 
was  no  appreciable  difference  in  length.  In  none  of  these  cases  had 
there  been  previous  fracture  or  any  bone  or  joint  disease  which  might 
have  accounted  for  the  defect.  Three  of  the  boys,  including  those  that 
exhibited  the  greatest  shortening,  were  aware  of  the  fact  that  one  limb 
was  deficient  in  length.  Burrell ' 
reported  three  cases  of  marked 
unilateral  atrophy  only  noticed 
when  the  children  began  to  walk, 
when  it  became  manifest  by  a 
limp. 

Broca  '  relates  the  case  of  a  boy 
of  eleven  who  appeared  "  as  if  the 
two  halves  of  the  body  were  differ- 
ent-sized persons  joined  together." 

Paget '  found  that  there  is  often 
a  difference  of  volume  as  marked 
as  is  the  difference  in  length,  and 
it  is  often  difficult  to  say  which 
of  the  two  unequal  limbs  is  the 
better  or  the  more  appropriate  to 
the  other  parts  of  the  body.  In 
Hartwig's  studies  of  the  upper  ex- 
tremity the  bones  of  the  right  arm 
were  found  to  be  the  longest,  cor- 
responding with  Hyrtl's  results. 
Poncet '  reported  a  case  of  alter- 
nate inequality,  the  right  arm 
and  the  left  leg  being  better  de- 
veloped. 

The  conclusions  reached  by  all  have  been  nearly  identical,  namely, 
that  throughout  the  long  bones  of  both  extremities  there  exists  often  a 
certain  amount  of  asymmetry  in  regard  to  length. 

The  very  important  theoretical  and  practical  bearing  of  this  is  easily 
seen.  The  relation  that  short  limbs  may  bear  to  cases  of  lateral  curva- 
ture '  has  been  discussed. 


Fig.  410.— Case  of  Multiple  Plexiform  Fibro- 
ma. Causing  Hypertrophy  and  much 
Lengthening  of  Left  Leg.     (H  L.  Burrell.) 


^  "  Asymmetry  of  the  Lower  Limbs,"  etc.     Phila.  Med.  Times,  July  loth,  1S86. 

-Boston  Med.  and  Surg.  Journal,  vol.'  cvi.,  p.  462. 

■^Canstatt's  Jahresbericht,  1859,  vol.  iv.,  p.  6. 

''Am.  Journal  Med.  Sciences,  January,  1886. 

=  Lyon  Me'dical,  January  29th,  188S. 

"  Revue  de  Chirurgie,  April  loth,  1888. 


47 S  ORTHOPEDIC  SURGERY. 

The  progressive  facial  hemiatrophy  is  of  interest  from  an  etiological 
standpoint. 

The  etiology  of  these  different  forms  of  atrophy  or  hypertrophy  is 
obscure.  In  the  cases  of  injury  to  the  joints  Nicoladoni  suggested  a 
premature  synostosis  of  the  epiphyseal  cartilages.  The  facial  hemi- 
atrophy is  thought  to  be  a  trophic  neurosis  of  certain  nerve  ganglia  or 
nerves — or  a  simple  vascular  disturbance  of  the  part  has  been  sug- 
gested as  a  possible  cause. 

It  is  probable  that  certain  of  these  cases  are  the  result  of  a  slight 
former  hemiplegia,  which  has  manifested  itself  chiefly  in  retarding  the 
growth  of  the  affected  side  without  any  distinct  loss  of  motor  power. 

Symptoms  and  Treatment. — Long-continued  slight  and  oftentimes 
severe  backaches,  with  lumbar  and  pelvic  pain,  involving  the  distribu- 
tion of  the  sciatic  nerve,  are  often  due  to  asymmetry  of  the  lower 
limbs.  Such  symptoms  are  at  times  at  once  relieved  upon  correcting 
the  asymmetry  b}'  increasing  the  height  of  the  shoe  of  the  shortened 
limb.  A  person  in  previous  good  health  may  from  some  depressing 
physical  condition  begin  to  have  the  above  symptoms  of  pain  localized 
as  stated,  and  upon  examination  unequal  limbs  will  be  found  in  very 
many  cases. 

Morton  said  that  United  States  pension-examining  surgeons  stated 
that  many  applications  for  pension  have  been  made  for  disabilities  de- 
scribed as  lumbago,  supposed  to  have  been  caused  by  exposure  or  by 
injuries  contracted  during  the  war  for  the  Union.  In  nearly  all  such 
cases  an  examination  revealed  a  previously  unrecognized  asymmetry, 
and  the  symptoms  were  probably  induced  by  this  defect  in  develop- 
ment. 

Symptoms  of  inequality  of  the  lower  limbs  may  simulate  coxalgia. 
In  such  cases  the  legs  should,  of  course,  be  measured.  Children  com- 
plaining of  backache,  or  so-called  growing  pains,  should  be  carefully 
examined  for  any  such  anatomical  defects. 

The  medico-legal  bearing  of  the  fact  of  asymmetry  has  been  called 
attention  to  by  Hunt  in  the  paper  already  referred  to. 

Hypertrophy  of  the  limbs  may  occur  either  from  dilatation  of  the 
vessels  (as  in  angioma),  from  disease  of  the  lymphatics,  and  from  con- 
genital anomaly.' 

'"Clinical  Report  Children's  Hospital  Service."  Boston  Aled.  and  Surg. 
Journ..  cxliv.,  14.  p.  329. 


CHAPTER   XVIII. 
CONGENITAL    DISLOCATIONS. 

Congenital  dislocation  of  the  hip. — Frequency  and  occurrence. — Etiology. — Pa- 
thology. —  Symptoms.  —  Diagnosis.  —  Differential  diagnosis.  —  Prognosis.  — 
Treatment. — (Reduction  with  aid  of  mechanical  force. — Tenotomy,  fasciotomy. 
— After-treatment. — Relapses. — Osteotomy. — Treatment  of  older  and  adult 
cases. — Summary.) — Congenital  dislocation  of  other  joints. — Knee. — Patella. 
— Congenital  absence  of  the  patella. — Ankle. — Shoulder. — Elbow.  —  Wrist 

Cubitus  valgus,  cubitus  varus.  — Spontaneous  subluxation  of  the  wrist. 

CONGENITAL    DISLOCATION   OF    THE    HIP. 

Congenital  dislocation  of  the  hip  is  neither  a  common  affection 
nor  one  of  very  great  rarity.  Among  6,969  orthopedic  patients  apply- 
ing at  the  out-patient  department  of  the  Children's  Hospital,  there 
were  152  cases  of  congenital  dislocation  of  one  or  both  hips.  Chaus- 
sier,  in  23,293  infants  born  at  the  Maternite,  found  only  i  case  of  con- 
genital luxation.  But  it  is  probable  that  it  occurs  in  reality  much 
oftener  than  it  is  recognized  clinically.  Parise  dissected  the  hip-joints 
of  all  children  d3dng  while  he  was  interne  at  the  Hopital  des  Enfants 
trouves,  and  in  332  he  found  congenital  dislocation  of  one  or  both  hips 
in  3. 

The  distribution  of  the  affection  between  the  sexes  and  in  one  or 
both  joints  can  be  seen  from  the  following  tabulation  of  collected 
cases : 

Single 
Number.    Boys.    Girls.    Right.  Left.    Double. 

Drachmann 77  10        67  24       24  29 

Pravaz 107  11         96  27       29  51 

Kronlein 90  14         76  32       22  31 

N.  Y.  Orth.  Hosp.  and  Disp 25  2         23  5       10  5 

Boston  Children's  Hospital ' 24  o        24  7       11  6 

Prahl iS  31;  GO  o 


341  40      301         93       96        122 

The  affection  is  much  more  common  in  girls  than  in  boys,  301  of 
these  341  cases  (88  per  cent)  having  been  observed  in  females.  No 
satisfactory  explanation  has  been  advanced  to  account  for  this  prepon- 
derance in  girls. 

Etiology.^The  etiology  of  the  affection  is  not  known.  True  con- 
genital dislocation  without  doubt  is  an  affection  of  uterine  life,  congeni- 
tal dislocations  having  been  found  in  the  foetus.     It  would  seem  also 

479 


48o 


ORTHOPEDIC  SURGERY. 


that  it  is  not  an  arrest  of  development  like  harelip,  but  like  congenital 
club-foot  rather  a  perversion  of  it,  a  malposition  of  bones  with  the  re- 
sulting structural  changes  of  the  soft  parts.  Violence  at  birth  alone,  is 
not  considered  the  cause  of  true  congenital  dislocation.  The  theor}" 
that  the  deformity  is  due  to  intra-uterine  pressure  at  a  period  of  foetal 
development  is  held  by  many.'  This  theory,  however,  does  not  explain 
the  fact  that  the  affection  is  much  more  frequent  among  girls  than 
among  boys.     The  lack  of  complete  development  in  the  acetabulum 


Fig.  411. — Lordosis  and  Prominence  of  Tro- 
chanters in  Congenital  Dislocation  of  the 
Hip.     0-  S.  Stone.) 


Fig.  412. — Unilateral  Dislocation  of  the 
Hip.     (Fiske  Prize  Fund  Essaj'.) 


described  by  many  writers  will  be  found  after  thorough  examination  of 
pathological  specimens  to  be  explained  by  the  malposition  of  the  parts 
during  a  portion  of  the  period  of  foetal  life  rather  than  by  a  structural 
arrest  of  development. 

'  A  specimen  was  described  by  Air.  Jackson  Clark  in  which  in  uterine  Hfe  the 
thighs  were  flexed  for  so  long  a  period  without  extension  as  to  cause  firm  contrac- 
tion of  the  anterior  portion  of  the  capsule.  Later  extension  of  the  limb,  possibly 
from  an  increase  of  the  amniotic  fluid  or  from  any  cause,  would,  in  a  shallow 
acetabulum,  cause  dislocation  of  the  hip  (Brit.  Ortho.  Trans.,  vol.  i.). 


CONGENITAL  DISLOCATIONS. 


481 


There  is,  undoubtedly,  a  tendency  to  heredity  in  congenital  hip  dis- 
location. Dupuytren  relates  the  case  of  three  families  in  which  the 
affection  was  present  in  several  members,  and  cases  are  related  by 
Bouvier,'  Verneuil,  Stadfeldt,  Caswell,  and  Volkmann.  It  has  been 
observed  in  two  instances  at  the  clinic  of  the  Children's  Hospital.  In 
each  instance  two  sisters  were  similarly  affected. 

Pathology. — The  changes  in  the  anatomical  structures  seen  in  con- 
genital dislocation  are  found  in  the  capsule,  in  the  muscles,  and  in  the 


Fig.  413. — Prominence  of  Trochanters  in 
Double  Congenital  Dislocation  of  the 
Hip.     (Fiske  Prize  Fund  Essay.) 


Fig.  414. — Lordosis  in  Double  Congenital 
Dislocation  of  the  Hip.  (Fiske  Prize 
Fund  Essay.) 


bones.  The  changes  in  the  capsule  are  such  as  would  naturally  follow 
a  prenatal  dislocation  before  the  joint  structures  were  formed.  Nor- 
mally the  capsule  passes  from  the  rim  of  the  acetabulum  to  the  neck  of 
the  femur,  the  head  being  placed  well  in  the  socket.  In  congenital  dis- 
location, when  the  head  lies  out  of  the  socket  and  above  the  acetabu- 
lum, the  capsule  is  stretched.  Furthermore,  the  weight  of  the  body, 
as  soon  as  the  individual  walks,  rests  not  on  the  head   of  the  femur 

'  Bouvier :  "  Leq.  Clin,  sur  les  Mai.  chron.  de  TApp.  locomoteur." 
31 


482 


ORTHOPEDIC  SURGERY. 


\ 


placed  under  the  acetabulum,  but  falls  upon  the  capsule,  which  stretches 
like  a  strap  from  the  acetabulum  to  the  trochanter,  and  this  capsule 
necessarily  becomes  thickened.  As  it  is  stretched  across  the  acetabu- 
lum it  becomes  adherent  at  the  rim  and  to  a  portion  of  the  ilium,  so 
that  the  acetabulum  seems  obliterated,  being  covered  by  thick,  strong, 
fibrous  tissue,  reaching  from  rim  to  rim.  This  portion  of  the  capsule 
is  entirely  shut  off  by  adhesion  from  that  which  surrounds  the  head, 
save  for  a  small  opening  at  the  upper  portion  of  the  rim.  This  open- 
ing may  be,  and  usually  is,  smaller    than  the  head,    and  not    easily 

stretched,  as  the  tissues  lose  their  elas- 
ticity owing  to  the  fibrous  bands  which 
form  from  the  use  of  the  capsule  as  a 
weight-bearing  structure. 
f  The  muscles  are  changed  in  conse- 
quence of  the  altered  position  of  the  head. 
Some  of  the  muscles  are  shortened,  others 
are  lengthened.  The  muscles  which  are 
shortened  are  the  adductor  group,  the 
psoas  and  iliacus,  and  the  muscles  reach- 
ing from  the  tuberosity  of  the  ischium  to 
the  leg,  i.e.,  the  hamstring  muscles.  The 
glutaei  muscles  are  not  shortened,  and  the 
group  of  muscles  which  pass  from  the 
pelvis  to  the  greater  trochanter,  the  ob- 
turators, gemelli,  etc.,  are  lengthened. 
The  capsular  and  periarticular  ligaments 
adapt  themselves  to  the  position  of  the 
deformity,  and  those  which  are  attached 
to  the  lesser  trochanter  are  particularly 
strong  and  firm  to  prevent  the  pushing  of 
the  head  upward,  when  weight  falls  upon 
the  leg.  It  is  these  tissues  which  oppose 
any  attempt  at  reduction,  and  unless  they 
are  stretched  or  divided  the  deformity  can- 
not be  corrected.  The'  alteration  in  the 
bone  consists  of  a  flattening  or  alteration 
of  the  shape  of  the  head,  a  twist  of  the  neck,  the  consequence  of  mal- 
position of  the  head,  and  in  the  shape  of  the  acetabulum,  which  is 
sometimes  triangular  in  shape  and  shallow. 

Three  varieties  of  congenital  dislocation,  classified  according  to  the 
position  of  the  head,  are  mentioned,  viz.,  backward,  upward,  or  forward. 
The  backward  or  dorsal  is  much  the  most  common. 

If  the  point  of  suspension  is  directly  over  the  proper  place  for  the 
acetabulum,  the  patient's  pelvis  is  hung  in    a  comparatively  normal 


M 


-**' 


Fig.  415. — Rroadening  of  Perineum 
in  Double  Congenital  Disloca- 
tion of  the  Hip.  (Fiske  Prize 
Fund  Essay.) 


CONGENITAL  DISLOCATIONS. 


483 


plane,  but  if  much  behind  it  the  pelvis  is  tilted  and  severe  lordosis  re- 
sults,' the  latter  being  the  more  common  condition.^ 

Symptoms. — The  deformity  usually  attracts  no  attention  until  the 
child  learns  to  walk  at  the  age  of  two  or  even  three  years.  Then  it  is 
noticed  to  stand  ordinarily  with  its  back  very  much  arched  and  to  wad- 
dle most  markedly  when  walking  is  well  begun.  This  waddle  is  char- 
acteristic and  very  marked.  When  the  dislocation  is  only  unilateral, 
the  waddle  becomes  an  exaggerated  limp ;  in  stepping  on  that  leg  the 
child  leans  to  the  affected  side,  and  the  leg  seems  to  have  grown  sud- 
denly shorter;  the  child  recovers  itself  at  once  and  goes  on  with  this 
sudden  giving  way  whenever  the  affected  leg  is  stepped  upon.      In 


Fig.  416.— Congenital  Dislocation  of  the  Hip  in  Full-term  Foetus.     (Warren  Museum.) 


double  dislocation,  in  young  children,  the  prominence  of  the  trochan- 
ters is  not  marked  enough  to  attract  attention ;  in  older  persons,  how- 
ever, the  prominence  of  the  trochanters  and  buttocks  is  most  notice- 
able. There  is  no  complaint  of  pain  by  children  suffering  from  this 
affection. 

Diagnosis. — The  diagnosis  rests  chiefly  on  one  point,  the  position 
of  the  trochanters  above  Nelaton's  line,  which  is  drawn  from  the  ante- 
rior superior  spine  of  the  ilium  to  the  tuberosity  of  the  ischium.  In 
small,  plump  children  it  is  sometimes  difficult  to  determine  accurately 
whether  the  trochanter  is  on  the  line  or  very  slightly  above  it.  The 
displacement  of  the  trochanter  upward  varies  from  half  an  inch  to  one 

'  The  pathological  condition  of  congenital  dislocation  has  been  recently  most 
thoroughly  investigated  by  Dr.  E.  H.  Nichols,  of  Boston,  to  whom  the  writers  are 
indebted  for  information  on  the  subject  (Trans.  Am.  Orth.  Assn.,  1896). 


484 


ORTHOPEDIC  SURGERY. 


or  two  inches,  according  to  the  severity  of  the  case,  but  on  careful  pal- 
pation the  head  of  the  femur  can  often  be  felt  on  deep  pressure  if  the 
limb  is  rotated,  as  moving  in  an  abnormal  excursion  outside  of  the  ace- 
tabulum. 

As  the  child  lies  on  its  back,  the  perineum  is  noticed  to  be  unusu- 
ally broad  in  double  dislocation,  the  legs  will  perhaps  be  everted,  per- 
haps in  normal  position,  and  on  manipulating  them  they  will  be  found 
in  young  children  to  be  unusually  movable,  especiall}'  in  the  direction 
of  eversion. 

On  pulling  the  leg  with  gentle  force  the    trochanter  will  be  felt 


Fig.  417. — Congenital  Dislocation  of  the 
Hip  in  Full-term  Foetus.  Capsule  re- 
moved.    (Warren  Museum.) 


Fig.  41S. — Specimen  of  Congenital  Dislocation  of 
Hip.  A^  Capsule  stretched  around  distorted 
head  ;  j9,  portion  of  contracted  capsule  ;  C,  cap- 
sule leading  to  acetabulum. 


drawn  down,  if  the  other  hand  is  placed  upon  it,  and  to  slip  back  when 
the  leg  is  released,  and  a  measurement  will  show  that  the  leg  has  been 
lengthened  temporarily  bv  the  traction  force. 

The  muscles,  although  not  normally  developed,  are  not  paralyzed, 
and  the  children  are  ordinarily  healthy  ones.  In  unilateral  dislocation, 
the  leg  of  the  affected  side  is  slightly  smaller  than  the  other. 

In  larger  children  and  adults  the  conformation  and  outline  of  the 
hips  are  so  distinctive  that  the  diagnosis  may  be  made  almost  at  a 
glance ;  but  in  young  children  palpation  or  a  skiagraphic  examination 
is  often  necessary. 


CONGENITAL  DISLOCATIONS. 


485 


Trendelenburg  has  called  attention  to  an  important  diagnostic 
symptom.  When  a  normal  child  stands  upon  either  limb  and  flexes 
the  other  at  the  knee  and  thigh,  the  opposite  buttock  will  be  seen  not 
to  drop.  In  the  case  of  congenital  dislocation  of  the  hip,  however,  the 
opposite  buttock  will  be  found  to  drop  to  a  noticeable  degree  if  the 
patient  takes  this  attitude.  This  is  to  be  explained  by  the  fact  that  in 
congenital  dislocation  of  the  hip,  owing  to  the  fact  that  the  head  of  the 
femur  is  not  in  the  socket,  the  muscles  from  the  great  trochanter  and 
the  pelvis  (which  serve  to  keep  the  pelvis  level)  when  supported  on  one 
side  have  no  purchase  and  are  therefore  inefficient. 

In  small  children  with  fat  buttocks  it  is  sometimes  difficult  to  find 


Fig.  419.  — Congenital  Dislocation,  Child  of  Ten.  Femur 
sawn  and  sides  reilected,  showing  dislocated  position  of 
the  femoral  head,  the  capsular  pouch,  the  capsular  hy- 
men in  front  of  the  acetabulum,  the  acetabular  cavity, 
and  capsular  constriction  at  the  mouth.  (Warren  Mu- 
seum.) 


J 


\    - 

Fig.  420. — Congenital  Dislo- 
cation of  the  Hip.  Cross 
section  of  femur  and  ace- 
tabulum (femur  tttrned 
back),  showing  capsular 
constriction  at  mouth  of 
acetabulum.  Child  three 
5"ears  old.  (Warren  Mu- 
seum.) 


with  certainty  the  dislocated  head.  The  diagnosis  is  aided  by  remem- 
bering that  when  the  head  of  the  femur  is  in  the  acetabulum,  rotation 
takes  place  with  the  acetabulum  as  the  centre,  and  the  neck  as  the  ra- 
dius of  the  arc  of  motion;  when  the  head  is  out  of  the  acetabulum,  the 
trochanter  is  the  centre  of  motion,  and  the  looser  head  describes  the 
arc. 

A  skiagraphic  picture  is  of  great  value  in  diagnosis,  and  if  accurate 
is  conclusive. 

Differential  Diagnosis. — The  following  affections  may  be  confounded 


486 


ORTHOPEDIC  SURGERY. 


with  congenital  dislocation  of  the  hip  in  smaller  children :  coxa  vara, 
distortion  following  infantile  paralysis,  separation  of  the  epiphysis,  de- 
formity following  early  arthritis  of  infancy,  traumatic  dislocations,  and 
the  deformities  of  hip  disease. 

In  all  these  affections,  with  the  exception  of  the  first,  viz.,  coxa  vara, 
there  should  be  a  history  of  previous  injury  or  illness;  and  in  all,  with 
the  exception  of  coxa  vara  and  infantile  paralysis,  the  freedom  of  motion 
of  the  femur  seen  in  early  congenital  dislocation  is  not  found. 

Coxa  vara,  or  the  distortion  of  the  neck  of  the  femur,  which  short- 
ens the  limb   and  raises  the  trochanter  above  Nekton's  line,  may  be 


Fig.  421. — Femur  in  Congenital  Dislocation,  Showing  Alteration  in  Angle  of  Neck. 

confounded  with  congenital  dislocation.  The  mistake  can  be  avoided  if 
the  fact  is  borne  in  mind  that  in  coxa  vara  the  head  is  in  its  normal 
socket,  while  in  congenital  dislocation  the  head  is  to  be  felt  outside  of 
the  acetabulum.  Coxa  vara  is  only  very  exceptionally  noticed  as  early 
as  three  years  of  age. 

The  affection  of  congenital  dislocation  is  occasionally  regarded  as  a 
disease  of  the  spine,  as  marked  lordosis  is  always  present,  and  in  many 
instances  spinal  corsets  have  been  applied  with  the  idea  that  this  is  the 
chief  source  of  the  trouble. 


CONGENITAL  DISLOCATIONS.  487 

Prognosis. — The  disability  caused  by  this  affection  in  childhood  is 
slight.  The  limp  is  noticeable,  and,  in  double  congenital  dislocation, 
may  be  distressing.  As  the  patient  becomes  older  and  the  weight 
increases,  some  annoyance  may  be  caused  in  adolescence;  but  this 
ordinarily  is  not  great  until  middle  life  or  old  age.  In  single  disloca- 
tion the  defect  in  adults  may  be  only  an  inability  to  engage  in  active 
occupation,  accompanied  by  occasional  attacks  of  severe  muscular 
pain,  with  muscular  cramps.  These  attacks  subside  under  rest,  but 
if  the  patient  becomes  heavier  or  feeble  they  may  necessitate  the  use 
of  crutches  and  cause  severe  disability.  When  the  dislocation  is  on  the 
dorsum  the  disability  is  greater  than  when  it  is  anterior  or  above  the 


Fig.  422. — Old  Cong-enital  Dislocation  of  Hip  with  Alteration  of  Neck  of  Femur  to  Shape  of 
Acetabulum.     (Warren  Museum.) 

acetabulum.  Muscular  patients  suffer  less  than  those  with  feeble  mus- 
cles.    In  double  dislocation  the  trouble  is  increased. 

No  strong  acetabulum  develops  around  the  dislocated  head,  and 
with  the  body  suspended  from  the  femurs  by  a  loose  capsular  ligament, 
the  patient  goes  through  life  walking  with  discomfort  and  effort  at  each 
step,  always  preserving  that  most  characteristic  swaying  from  side  to 
side. 

It  may  be  said  that  in  general  the  tendency  of  these  cases  when 
untreated  is  to  remain  stationary  or  to  grow  somewhat  worse.  The 
pelvis,  although  altered  in  shape,  does  not  appear  to  be  changed  in  such 
a  way  as  to  interfere  with  childbirth. 


488 


ORTHOPEDIC  SURGERY. 


The  prognosis  in  cases  which  are  treated  will  be  considered  under 
that  head. 

Treatment. — Attempts  at  reduction  without  operation  have  proved 
unsuccessful,  although  cases  by  Pravaz,  Buckminster  Brown,  and 
Adams  were  thoroughly  treated  by  traction  for  a  long  period  and  ap- 
parently benefited  at  first.  The  ultimate  results  were,  how^ever,  en- 
tirely unsatisfactory,  and  the  method  cannot  be  recommended. 

Operative   measures-  when    first     attempted    without    a    thorough 


Fig.  423.— Congenital  Dislocation,  Showing 
Dropping  of  Pelvis  when  Patient  Stands 
on  the  Affected  Limb. 


Fig.  424. — Coxa  Vara,  Showing  Elevation  of 
Pelvis  when  Patient  Stands  on  Affected 
Limb. 


knowledge  of  the  pathological  conditions  also  failed,  but  through  the 
valuable  work  of  Hoffa  and  Lorenz  successful  operative  methods  have 
been  developed  and  a  reasonable  and  increasing  percentage  of  success 
is  obtained  in  suitable  cases. 

Mechanical  treatment  and  the  treatment  by  traction  continued  for  a 
long  period,  advocated  by  Pravaz,  Adams,  and  Buckminster  Brown. 
have  not  given  results  which  were  permanently  successful. 

The  operative  methods  may  be  termed : 

1.  Reduction  by  open  incision. 

2.  Reduction  by  forcible  manipulation. 


CONGENITAL  DISLOCATIONS. 


489 


Reduction  by  Open  Incision. 

To  Hoffa  belongs  the  credit  of  having  first  presented  to  the  pro- 
fession an  operative  method  of  value.  This  has  been  modified  by 
Lorenz  and  himself  and  may  be  described  as  follows : 

The  patient  is  to  be  placed  upon  the  back  with  the  limbs  slightly 


Fig.  425. — Double  Congenital  Dislocation  Unreduced. 

abducted  and  rotated  outward.     The  incision  is  made  in  a  line  drawn 
from  in  front  of  the  anterior  superior  spine,  obliquely  downward  and 


Fig.  429.— Fourth  Step. 


Fig.  426.— Line  of  In-     FiG.  427.— Second        Fig.  428.— Third 
cision    for    Opera-  Step.  Step, 

five  Reduction. 

backward,  crossing  the  femur  a  short  distance  below  the  top  of  the  tro- 
chanter. The  incision  should  be  along  the  outer  edge  of  the  tensor 
vagina  femoris,  between  this  and  the  anterior  border  of  the  glutseus 


490 


ORTHOPEDIC  SURGERY 


Fig.  430. — Congenital  Dislocation  Reduced. 


CONGENITAL   DISL  O  CA  TIONS. 


491 


medius.  The  incision  should  pass  well  below  the  top  of  the  femur,  and 
should  cross  it  slightly  above  the  level  of  the  trochanter  minor.  The 
tensor  vaginse  femoris  is  retracted  and  the  fascia  lata  divided  by  a 
straight  incision,  and,  if  necessary,  by  an  additional  cross  incision.  The 
glutsEus  is  also  retracted,  and  beneath  the  tensor  muscle  the  rectus 
femoris  will  be  found,  with  a  reflected  tendon  passing  outward,  to  be 
attached  to  the  ilium  above  the  acetabulum.  If  the  muscular  tissues 
are  well  retracted  the  capsule  will  be  uncovered  and  can  be  split,     this 


Fig.  431.— Congenital  Dislocation.  Reduction  bj-  incision.     Osteotomy  of  shaft  to  correct 

twist  of  neck. 

should  be  done  by  an  incision  in  the  direction  of  the  original  skin  incis- 
ion, and  should  be  free  enough  to  expose  the  whole  head  and  neck  as 
far  as  the  trochanteric  line,  and,  if  necessary,  a  cross  incision  is  made. 
An  assistant  should  flex  the  thigh  to  a  right  angle  to  the  trunk,  and 
the  attachments  of  the  capsule  to  the  neck  and  the  trochanteric  line, 
including  the  lesser  trochanter,  should  be  thoroughly  freed  both  on  the 
anterior  and  posterior  surface  of  the  neck  to  such  an  extent  that  the 
surgeon  can  pass  his  finger  completely  around  the  neck.  The  head  can 
then  be  thrown  out,  the  ligamentum  teres  having  been  divided,  if  pres- 


492  ORTHOPEDIC  SURGERY. 

ent.  The  head  of  the  femur  can  then  be  pulled  aside  and  a  clear  view 
of  the  capsule  covering  the  acetabulum,  as  well  as  the  acetabulum,  can 
be  had.  If  the  capsule  is  constricted  above  the  acetabulum  it  can  be 
cut  with  a  herniotome  or  stretched  with  a  dilator  or  enlarged  with  a 
curette.  It  is  important  that  the  bony  edge  overhanging  the  acetabu- 
lum should  project  sufficiently  to  furnish  a  firm  socket  after  the  head  is 
reduced.  It  is  sometimes  difficult,  if  the  tissues  are  imperfectly  divided, 
to  find  the  socket,  for  the  reason  that  a  portion  of  the  capsule  lies  flat 
across  the  socket  and  is  adherent  to  the  edges,  the  surgeon  feeling  only 
the  upper  edge  and  a  mass  of  connective  tissue ;  but  when  this  difficulty 
is  met  it  is  necessary  to  enlarge  the  incision,  as  it  is  essential  that  the 
head  be  placed  well  in  the  socket.     It  is  not  infrequently  necessary  to 


Fig.  432. — Double  Congenital  Dislocation  of  the  Hip.  Reduction  on  left  side  by  open  incision. 
Relapse  on  right  side  after  attempted  manipulative  reduction.  Capsular  constriction  at 
mouth  of  right  acetabulum.     Death  six  months  after  operation. 

deepen  the  acetabulum  by  means  of  a  curette  or  gouge.     This  is  neces- 
sary if  the  acetabulum  is  abnormally  shallow. 

It  is  sometimes  necessary,  if  the  head  of  the  femur  is  conical  in 
shape,  to  remove  a  portion ;  but  if  the  cartilage  on  the  acetabulum  is 
removed  and  the  head  of  the  femur  freed  from  its  cartilage,  ankylosis 
is  liable  to  result.  It  is  particularly  necessary  that  the  capsule  should 
not  be  folded  in  attempted  reduction  in  such  a  way  as  to  prevent  the 
free  entrance  of  the  head  into  the  acetabulum,  and  it  is  especially  impor- 
tant that  the  connection  between  the  acetabulum  and  the  femur  at  the 
trochanteric  line  and  lesser  trochanter  should  not  be  so  firm  as  to  pre- 
vent the  easy  reduction  of  the  head  into  the  socket.  When  it  is  found 
that  the  head  when  reduced  into  the  socket  will  not  remain  there  if  the 
leg  is  adducted  or  extended,  some  remaining  fibres  of  the  capsular  at- 
tachments on  the  anterior  surface,  passing  from  the  ilium  to  the  lesser 


CONGENITAL  DISLOCATIONS. 


493 


trochanter  and  its  adjacent  parts,  will  be  found  to  exist.  After  the 
acetabulum  has  been  deepened  sufficiently,  the  reduction  of  the  disloca- 
tion should  be  performed. 

After  the  reduction  the  redundant  capsule  can  be  closed,  with  a 
wick  for  drainage,  or  packed,  according  to  the  judgment  of  the  surgeon. 


Fig. 


-Diagram  of  Section  of  Capsule  in  Normal  and  in  Congenitally  Dislocated  Hip. 


Drainage  is  to  be  regarded  as  of  importance,  as  the  cavity  is  a  deep  one 
and  may  be  shut  off.  Furthermore,  in  this  region  the  danger  of  infec- 
tion from  urine,  in  small  children,  is  to  be  considered.  The  experience 
at  the  Boston  Children's  Hospital  has,  however,  been  in  favor  of  clos- 


FIG.  435. 


Fig.  434. 
Figs.  434  and  435.— Diagram   Showing  Difficulties  in   Reduction,     i,  In  the  capsule  covering 
the  acetabulum  ;  2,  in  the  shortened  capsule  between  the  acetabular  rim  and  the  lesser 
trochanter. 

ing  the  wound  at  the  time  of  operation,  leaving  only  a  gutta-percha 
tissue  wick,  to  be  removed  in  a  short  time.  When  absolute  confidence 
can  be  placed  in  thorough  asepsis,  closing  the  wound  in  this  way  at 
the  time  of  operation  saves  for  the  patient  a  long  period  of  wound- 


494 


ORTHOPEDIC  SURGERY, 


healing.  The  hmb  should  be  flexed  by  means  of  a  plaster-of -Paris  spica 
reaching  from  the  thorax  down  to  the  foot,  holding  the  limb  in  a 
strongly  abducted  position.  The  position  of  the  limb  can  be  gradually 
brought  to  normal  by  later  application  of  plaster-of-Paris  bandages. 

Reduction  by  Forcible  AIaxipulatiox. 

This  method,  requiring  necessarily  the  employment  of  an  anaesthetic, 
was  first  attempted  by  Post,  of  Boston,  without  a  permanent  successful 
result.  Paci,  at  the  International  ]\Iedical  Congress  in  Rome,  showed 
several  cases  successfully  treated  by  a  manipulative  method  of  reduc- 
tion under  an  anjesthetic.  This  has  been  elaborated  by  Lorenz,  of 
Vienna,  who  has  extensively  demonstrated  the  details  of  the  method. 


Fig.  436.  Fig.  437. 

Figs.  436  and  437.  -Diagram  Showing  Pelvi-trochanteric  and  Pelvic  Muscles  in  Congenital 

Dislocation  of  Hip. 

The  method  of  manipulative  reduction  is  based  on  the  fact  that  in 
many  instances  the  head  can  be  placed  in  the  acetabulum  after  all  the  ob- 
structions caused  by  the  contracted  soft  parts  are  overcome  by  stretching, 
and  that  this  can  be  done  satisfactorily  by  using  the  femur  as  a  lever. 

Complete  anaesthesia  is  necessary.  The  child's  ankle  is  grasped 
firmly  and  a  strong  pull  exerted,  counter-pull  being  furnished  by  an  as- 
sistant who  presses  upon  the  perineum  or,  in  the  more  resistant  cases, 
pulls  upon  a  folded  sheet,  one  end  of  which  is  passed  under  the  peri- 
neum. The  limb  should  be  rotated  forcibly  to  both  the  outer  and  inner 
side,  and  then  forcibly  abducted  both  with  the  knee  flexed  and  straight. 

It  is  essential  that  the  adductor  group  of  muscles  should  be  over- 
stretched or  torn,  and  this  can  be  aided  by  forcible  massaging  or  by 
striking  with  the  hand  the  belly  of  the  long  adductor.  After  the  limb 
has  been  brought  to  a  right  angle  with  the  axis  of  the  trunk,  and  in 
some  instances  twenty  degrees  beyond,  the  knee  being  straight,  it 
should  be  again  brought  in  a  line  of  the  axis  of  the  trunk  and  then 
forced  upward  with  the  knee  straight,  until  the  thorax  is  touched  by  the 


CONGENITAL  DISLOCATIONS. 


495 


front  of  the  thigh,  thus  stretching  the  hamstring  muscles.  The  child 
should  then  be  turned  upon  its  face  and  forcible  hyperextension  used, 
both  with  the  leg  abducted  and  straight.  The  child  is  then  placed  upon 
its  back  and  reduction  attempted,  the  surgeon  holding  the  patient's 
limb  just  below  the  knee,  which  is  flexed  with  one  hand,  the  other  hand 
being  placed  upon  the  pelvis,  the  palm  pressing  on  the  crest  of  the 
ilium  and  the  thumb  passing  behind  and  beneath  the  trochanter.  The 
thigh  is  then  flexed  and  abducted,  and  with  the  limb  in  this  position  the 
operator  should  press  the  head  of  the  femur  downward  with  the  exer- 


FiG.  438. — Dissection  Showing  Tendinous  Insertion  of  the  Lower  End  of  the  Adductor  Magnus. 


else  of  strong  force,  to  stretch  the  lower  border  of  the  capsule.  The 
child  is  then  turned  upon  its  face  and  hyperextension  exerted,  both 
with  the  limb  abducted  and  in  a  line  with  the  body. 

The  child  is  then  placed  upon  its  back  and  an  attempt  at  reduction 
made.     If  the  tissues  have  been  sufficiently  stretched  by  the  above- 


496 


ORTHOPEDIC  SURGERY. 


mentioned  manoeuvres,  the  reduction  can  be  easily  made.  The  surgeon 
holds  the  patient's  limb  just  below  the  knee  with  the  hand,  abducts  the 
limb  strongly,  flexing  it  at  the  knee.  The  other  hand  is  placed  upon 
the  pelvis,  the  palm  of  the  hand  resting  on  the  anterior  spine,  and  the 
thumb  being  placed  under  the  trochanter,  while  an  assistant  steadies 
the  pelvis  by  pressing  upon  the  opposite  side.  The  patient's  knee  is 
pressed  downward  from  the  plane  of  the  operating  table,  while  the  tro- 
chanter is  pressed  upward  and  slightly  forward.  In  successful  cases 
the  head  will  be  felt  to  slip  into  the  acetabulum  with  a  sudden  move- 
ment characteristic  of  the  reduction  of  a  dislocation. 

It  is  often  necessary  to  give  slight  rotary  motion  to  the  limb  and 
slight  manipulation  is  often  necessary.     The  surgeon  can  use  the  head 


Fig.  439. — Manipulati%'e  Reduction  in  Congenital  Dislocation  of  the  Hip.     Traction  and 

reduction. 

of  the  femur  to  determine  the  size  and  depth  of  the  acetabulum,  and 
the  firmness  with  which  it  is  held  in  the  acetabulum  is  also  to  be  noted. 
In  the  more  resistant  cases  a  padded,  wedge-shaped  block  placed 
behind  the  trochanter  will  be  of  assistance,  serving  to  push  the  tro- 
chanter and  head  of  the  femur  forward,  while  the  patient's  knee  is 
pressed  downward.  When  the  head  of  the  femur  is  well  in  the  acetab- 
ulum it  can  be  felt  on  careful  palpation,  lying  under  the  point  of  inter- 
section of  a  line  following  the  femoral  artery,  with  a  line  crossing  the 
pelvis  at  a  level  with  the  top  of  the  symphysis  pubis.  A  tightening  of 
the  hamstrings  will  usually  be  observed  on  reduction  of  the  hip.  After 
the  reduction  has  been  made,  the  limb  should  be  carefully  brought  into 
a  straight  position,  i.e.,  parallel  with  the  long  axis  of  the  trunk.  If  dislo- 
cation occurs  during  this  manipulation  the  tissues  must  be  stretched 
still  further  and  the  head  again  placed  in  the  acetabulum. 


CONGENITAL  DISLOCA  TIONS. 


497 


Reduction  with  the  Aid  of  Mechanical  Force. 

In  the  younger  cases  little  difficulty  will  be  encountered  in  stretch- 
ing the  shortened  muscles  by  the  use  of  manipulation  as  described,  but 
in  older  cases  much  force  is  necessary,  which  involves  danger  of  fracture 
of  the  femur  or  pelvis,  both  of  which  accidents  have  occurred  in  manipu- 


FiG.  440.— Manipulative  Reduction.    Forced  abduction  stretching  the  adductors  with  blows 
upon  the  adductor  attachment. 

lative  reduction.  A  difficulty  encountered  where  manual  force  is  em- 
ployed is  in  holding  the  pelvis.  This  is  essential  to  the  accurate  em- 
ployment of  force,  and  the  accurate  employment  of  force  is  of  the 
greatest  importance  if  much  force  is  to  be  used. 

It  is  for  this  reason  that  mechanical  aids  have  been  advised  in  the 
reduction  of  congenitally  dislocated  hips.  One  of  the  most  efficient  of 
apparatus  for  the  purpose  is  an  appliance  devised  by  Mr.  Ralph  W. 
Bartlett,  of  Boston.'     It  consists  of  a  perineal  resistance  plate,  traction 


1    <5«- Si 


Fig.  441. — Manipulative  Reduction.     Forced  flexion  with  leg  straight  at  knee. 

rods,  and  cyhnders,  which  press  on  the  pelvis  at  and  above  the  tro- 
chanters. The  traction  rods  are  attached  to  the  cyhnders,  and  moving 
about  each  cylinder  is  a  metal  collar  controlled  by  a  handle.  The  collar 
is  armed  with  a  plate  which  can  be  made  to  press  the  trochanter  down- 
'  Jour,  of  Med.  Research,  new  series,  vol.  v.,  December,  1903,  pp.  440-448,. 


498 


ORTHOPEDIC  SURGERY. 


ward  and  forward.  The  cylinder  is  pivoted  upon  an  eccentric  pin,  and 
when  moved  by  a  wrench  can  be  made  to  increase  the  pressure  of  the 
trochanteric  plate. 

The  patient  is  placed  in  the  apparatus  with  the  perineum  pressing 
on  the  perineal  plate;  the  trochanteric  cylinders  are  adjusted  to  press 


Fig.  442. — Manipulative  Reduction.     Hyperextension. 

upon  and  above  the  trochanters.  The  patient's  ankles,  protected  by 
saddlers'  felt  and  leather,  are  connected  to  the  windlass  at  the  bottom 
of  the  traction  rods  by  means  of  rawhide  straps.     With  the  aid  of  this 


Fig.  443.— Manipulative  Reduction.    Head  of  femur  pressed  into  acetabulum  by  manipulation 
after  all  contracted  tissues  are  relaxed  by  overstretching-. 

mechanism,  traction  to  any  extent  can  be  applied,  and  in  connection 
with  it  a  strong  abducting  force,  with,  in  addition,  a  force  which  will 
press  the  trochanter  and  head  downward  when  the  limb  is  strongly 


CONGENITAL  DISLOCATIONS. 


499 


abducted.  The  danger  of  fracture  is  diminished,  as  the  replacing  force 
is  applied  when  the  head  is  pulled  away  from  the  pelvis. 

This  appliance  has  been  used  at  the  Boston  Children's  Hospital  for 
the  past  two  years,  after  careful  experiments  upon  cadavers,  and  its  effi- 
ciency proved  in  a  series  of  thirty  cases,  some  of  these  of  the  more 
resistant  type. 

The  Bartlett  machine  is  to  be  regarded  as  a  stretching  appliance 
rendering  the  manipulative  reduction  easy  after  the  thorough  stretch- 
ing.    In  some  instances  a  reduction  takes  place  by  the  aid  of  the  appa- 
ratus alone,   rotation  of   the   stretched 
limb  being  sufficient  to  lift  the  femoral 
head    into    the    acetabulum.      In    the 
more  difficult  cases,  however,  the  child 
is  to  be  removed  from  the  stretching 
apparatus    and   the  ordinary   manipula- 
tions applied. 

Tenotomy,  FasciotOxA-iy. — The  most 
important  tissues  other  than  the  cap- 
sule which  need  to  be  stretched  to  en- 
able the  surgeon  to  replace  a  congen- 
itally  dislocated  femoral  head  are  the 
adductor  group  of  muscles,  the  ham- 
strings, and  the  fascia  lata,  including  the 
ilio-femoral  band. 

The  adductor  group  of  muscles  can 
be  stretched  with  comparative  ease,  with 
the  exception  of  the  fibres  of  the  ad- 
ductor magnus,  which  pass  from  the 
tuberosity  of  the  ischium  and  are  col- 
lected into  a  tendon  of  considerable 
size,  which  is  inserted  in  a  tubercle 
above  the  internal  condyle  of  the  femur. 
These  fibres  are  not  of  importance  in 
limiting  the  adduction  of  the  limb  and 
are  not  s-tretched  by  forcible  abduction. 

They  do  serve,  however,  as  a  check  to  lengthening  the  lim.b,  and  in  re- 
sistant cases  offer  the  strongest  resistance  to  a  traction  force  needed 
to  pull  the  head  of  the  femur  down  to  the  level  of  the  acetabulum. 
This  resistance  can  be  readily  overcome  by  tenotomy  of  the  tendon  at 
the  lower  end  of  the  adductor  magnus.  If  a  small  incision  is  made  on 
the  inner  side  of  the  internal  condyle  of  the  femur,  this  tendon  can 
be  easily  found,  a  director  or  hook  passed  underneath  it,  and  a  divi- 
sion of  the  tendon  made  without  difficulty  by  a  scalpel  or  scissors. 
It  will   be  found   that   no   other   tissues  in  the  adductor  group   will 


Fig.  444. — Plaster  Fixation  after  Reduc- 
tion of  a  Congenitally  Dislocated  Hip. 
Foot  raised  to  improve  locomotion. 


500 


ORTHOPEDIC  SURGERY. 


offer   serious  obstacle  to   the   stretching   movements   preliminary   to 
reduction. 

The  ilio-tibial  band  which  offers  the  strongest  resistance  to  elonga- 
tion of  the  limb  can  be  readily  divided  by  a  tenotome  inserted  beneath 
the  skin  a  short  distance  above  the  external  condyle.  The  band  is 
from  an  inch  to  two  inches  in  width,  and  can  be  easily  felt  beneath  the 
skin  on  the  outer  side  of  the  leg  when  traction  is  applied  to  the  ankle. 


■t  m.r,und.     ^•,ttcf,tf.c    fi—,t-   C 

J)    arm  ^-«ii,„p  •>   %  a.$.re    ''.c-AoH^tr 

Pig.  443. — Details  of  Bartlett  Machine,  Showing  Effect  oi  Eccentric  Movement. 

In  double  congenital  dislocation  of  the  hip  where  lordosis  is  well 
developed,  the  anterior  portion  of  the  fascia  lata  offers  an  obstacle  when 
traction  is  applied,  this  force  acting  rather  to  increase  the  lordosis  than 
to  pull  down  the  femoral  head.  This  obstacle  can  be  overcome  by 
dividing  the  fascia  near  its  attachment  to  the  anterior  superior  spine. 
If  a  small  incision  is  made  through  the  skin  a  short  distance  below  the 
anterior  superior  spine  and  the  skin  is  retracted  the  fascia  can  be  divided 
freely. 

Althousfh  the  hamstrins:  muscles  offer   considerable  resistance  to 


CONGENITAL  DISLOCATIONS.  501 

pulling  down  the  dislocated  femoral  head,  tenotomy  of  their  tendons, 
though  easily  performed,  is  rarely  necessary,  for  the  reason  that  the 
resistance  of  these  muscles  can  be  readily  eliminated  by  flexing  the 
thigh  and  knee.  After  the  reduction  it  is  important  to  stretch  these 
muscles  that  the  limb  should  be  placed  in  a  normal  position  without 
dislocating  the  head.  This  can  usually  be  accomplished  by  forcible 
straightening  of  the  limb  with  the  knee  extended  after  the  head  has 
been  reduced.  The  above-mentioned  procedures  need  not  be  considered 
except  in  the  more  resistant  cases.  Xo  other  resistant  tissues  are  of 
importance,  with  the  exception  of  the  capsule. 

These  measures  are  usually  not  needed,  as  the  tissues  can  be 
stretched  without  resort  to  tenotomy  in  ordinary  cases. 

Accident s.~T\\Q.  method  of  reduction  of  congenital  femoral  disloca- 
tion by  manipulation  is  not  without  danger  and  requires  the  exercise  of 
considerable  judgment.     Fracture  of  the  femoral  head,  fracture  of  the 


Fig.  446.— Bartlett  Machine.     Reduction  of  congenital  dislocation  of  the  hip. 

pelvis,  death  from  shock,  rupture  of  the  femoral  artery,  temporary  and 
permanent  paralyses  have  all  followed  the  injudicious  use  of  force  in 
correcting  this  deformity.  These  accidents  can  be  avoided  if  the  method 
is  limited  to  the  less  severe  cases. 

Slight  paralyses  not  infrequently  follow  manipulative  reduction,  but 
pass  away  without  treatment  in  a  short  time. 

From  the  experience  at  the  Boston  Children's  Hospital  it  would 
appear  that  the  danger  of  injury  in  forcible  reduction  is  diminished  by 
the  employment  of  a  mechanical  appliance  similar  to  the  Bartlett  ma- 
chine. Great  care,  however,  and  judgment  are  necessary  in  the  use  of 
this  as  of  all  powerful  aids. 

After-Treatmext. — After  the  hip  has  been  placed  in  the  acetabu- 
lum, it  is  necessary  that  it  should  be  held  in  the  socket  until  the  capsu- 
lar tissues  are  sufficiently  strong  to  prevent  a  relapse. 

The  child,  while  still  under  the  anaesthetic,  is  placed  upon  a  pelvic 
support  and  a  firm  plaster  bandage  applied  to  the  thigh  and  pelvis,  pro- 
tected by  stockinet,  felt,  and  cotton.  The  thigh  should  be  flexed  and 
abducted  so  that  it  is  held  at  a  right  angle  with  the  long  axis  of  the 
body  and  with  the  inner  cond}-le  on  the  same  plane  as  the  symphysis 
pubis  or  a  little  lower.  In  this  position  the  muscles  are  at  a  disadvan- 
tage in  exerting  a  dislocating  force ;  the  neck  of  the  femur  points  for- 


502 


ORTHOPEDIC  SURGERY. 


ward  and  the  head  is  pushed  forward.  This  position  renders  difficult  a 
relapse  in  the  direction  of  a  backward  dislocation  and  favors  the  cica- 
trization of  the  posterior  capsular  tissues.  It  favors  anterior  displace- 
ment, however,  and  the  contraction  of  the  tissues  which  check  the 
bringing  of  the  limb  to  the  normal  straight  position. 

The  position  should  be  changed  as  soon  as  danger  of  a  relapse  in  a 
backward  direction  is  past.     If  it  is  necessary  to  retain  the  limb  in  the 


Fig.  447.— Six  and  One-half  Years  Old.     Congenital  dislocation  of  left  hip.     One  year  after 
reduction  by  ojjerative  mechanical  stretching  and  manipulation. 

Strongly  flexed  and  abducted  position  for  several  months,  the  limb 
should  be  rotated  daily  while  still  in  the  plaster,  to  check  the  contrac- 
tion of  the  pelvic  trochanteric  muscles.  After  the  danger  of  a  relapse  to 
a  posterior  dislocation  is  past,  the  limb  can  be  fixed  in  the  second  posi- 
tion. 

For  the  second  position  the  limb  is  brought  down  to  a  position  of 
abduction  of  forty-five  degrees.  In  cases  with  a  well-developed  socket 
and  well-reduced  head  the  limb  can  be  placed  in  this  position  imme- 


CONGENITAL  DISLOCATIONS.  503 

diately  after  operation.  It  is  the  practice  of  some  surgeons  to  allow 
the  patients  to  walk  about  immediately  after  reduction,  placing  a  high 
block  under  the  flexed  foot,  in  the  expectation  that  the  use  of  the  limb 
will  favor  a  deepening  of  the  socket.  For  this  the  plaster  needs  to  be 
cut  so  as  to  allow  motion  at  the  knee  and  free  motion  at  the  well  hip. 
It.  is  safer,  however,  to  fix  both  the  hip-joint  and  the  knee  of  the 
affected  side  for  a  few  wrecks  after  the  forcible  reduction,  carrying  the 


Fig.  44S.— Showing  Strength  of  Reduced  Hip  by  the  Trendelenburg  Test.     Motion  and  gait 

of  reduced  hip  normal. 

plaster  well  down  the  limb  and  around  the  opposite  perineum.  After 
the  tissues  have  recovered  from  the  laceration  of  reduction,  "the  plaster 
can  be  shortened  so  as  to  allow  the  patient  to  enjoy  more  freedom. 
The  length  of  time  during  which  it  is  necessary  that  the  plaster  band- 
age should  be  worn  varies,  with  each  case,  from  two  to  six  months  or 
even  a  year 

In  order  to  prevent  the  contraction  of  the  muscles  when  the  limb  is 
placed  in  the  plaster-of-Pans    spica,  it  is  desirable  not  only  that  the 


504  ORTHOPEDIC  SURGERY. 

child  should  walk  about  as  freely  as  possible  after  the  first  few  weeks 
following  the  operation  have  passed,  but  that  the  limb  be  rotated  inside 
the  plaster-of-Paris  spica  by  an  attendant,  who,  holding  the  patient's 
ankle,  endeavors  to  straighten  the  limb  at  the  knee  and  gently  turns 
the  foot  inward.  After  the  time  has  passed  when  plaster  fixation  is  no 
longer  necessary,  daily  exercise  should  be  given,  directed  to  increasing 
the  motion  at  the  hip-joint.  It  is  necessary  to  stimulate  the  muscles 
which  are  not  being  used,  and  to  stretch  by  gradual  exercise  the  mus- 
cles which  may  remain  contracted.  The  patient  should  be  given  both 
passive  and  active  exercises.  In  the  passive  exercises  the  manipulator 
should  place  one  hand  upon  the  pelvis  with  slight  pressure  above  the 
trochanter,  and  with  the  other  move  the  femur  in  the  direction  of  flex- 
ion and  adduction,  the  patient  being  recumbent.  Movement  should 
also  be  made  to  straighten  the  limb  at  the  knee  and  turn  the  foot  in- 
ward, bringing  the  limb  gradually  in  the  direction  parallel  with  the 
other.  Similar  active  exercises  can  be  undertaken  and  conducted  with 
care  daily. 

Relapses. — Although  it  may  be  claimed  that  a  large  number  of 
cases  of  single  congenital  hip  dislocations  under  ten  )-ears  of  age  can  be 
reduced  (with  or  without  the  aid  of  mechanical  force),  it  must  be  ad- 
mitted that  a  considerable  number  of  apparently  cured  cases  relapse. 
The  results  have  been  divided  by  Lorenz  into  anatomical  and  functional 
cures,  the  latter  term  being  applied  to  the  cases  in  which  the  femoral 
head  is  near  but  not  in  the  socket.  But  for  the  sake  of  accuracy  it  is 
desirable  to  avoid  classing  with  successful  cases  those  in  which  a  failure 
in  the  attempted  surgical  procedure  has  resulted,  even  if  the  patient's 
condition  may  have  improved. 

While  perfect  results  can  be  obtained  in  a  considerable  percentage 
of  cases  by  forcible  manipulative  reduction,  the  causes  of  relapse  need 
consideration.  One  of  the  most  common  is  wdiat  may  be  termed  im- 
perfect reduction,  i.e.,  a  reduction  into  the  acetabulum  with  the  folds 
of  the  enlarged  capsule  crowded  into  the  socket  in  front  of  the  femoral 
head.  In  some  instances  an  hour-glass  contraction  of  the  capsule  exists 
in  congenital  dislocation  of  the  hip,  too  great  and  too  firm  to  permit  the 
passage  in  attempts  at  reduction  of  the  femoral  head  through  the  con- 
stricted portion.  It  has  been  thought  that  the  use  of  the  limb  in  walk- 
ing in  the  after-treatment  enables  the  pressure  of  the  femoral  head  to 
wear  through  the  folded  capsule.  Evidence  to  support  this  is  lacking, 
and,  considering  the  toughness  and  nature  of  the  folded  capsule  and 
the  large  percentage  of  relapses,  it  is  probable  that  when  this  condition 
exists  (a  condition  verified  by  pathological  evidence  and  where  open 
incision  has  follow^ed  attempts  at  forcible  reduction)  relapse  is  inev- 
itable. 

Relapse  may  follow  where  the  capsular  tissue  fails  to  hold  with  suf- 


CONGENITAL   DISL  O CA  TIONS. 


505 


ficient  firmness  in  the  acetabulum  the  reduced  head  after  reduction. 
This  takes  place  when  a  cotyloid  ligament  is  not  developed,  and  when 


the  muscles  are  not  sufficiently  strong  to  keep  the  femoral  head  in 
place,  or  when  tissues,  contracted  in  the  flexed  and  strongly  abducted 


5o6 


ORTHOPEDIC  SURGERY. 


position   of  after-treatment,  prevent  the  placing  of   the   limb   in  the 
normal  position  without  causing  displacement. 

Care  in  after-treatment  may  prevent  relapses  in  many  instances  of 


'V^i 


■1  F 


this  class.     Careful  examination  of  the  cases  during  after-treatment  by 
manipulation  and  with  the  skiagraph,  the  use  of  gymnastics,  and  mas- 


CONGENITAL  DISLOCATIONS.  507 

sage  will  be  of  advantage  in  restoring  the  muscles  to  their  normal  con- 
dition. 

Relapses  result  also  from  abnormality  in  the  shape  of  the  femoral 
head  and  in  the  shape  of  the  acetabulum.  It  is  impossible  by  manipu- 
lative reduction  to  place  securely  a  distorted  femoral  head  into  an 
equally  distorted  and  smaller  acetabulum.  Permanent  reduction  is 
also  made  difficult  by  the  twist  of  the  femur,  which  gives  an  abnormal 
direction  to  the  femoral  neck  and  consequent  abnormal  muscular  rela- 
tion. The  importance  of  the  femoral  twist  in  causing  relapse  after  con- 
genital dislocation  has  been  exaggerated.  It  has  been  found  by  the 
investigation  of  Mikulicz  and  also  by  Soutter  that  a  femoral  twist  may 
exist  to  a  considerable  extent  without  causing  noticeable  disability. 
When  a  femoral  twist  of  ninety  degrees  is  present,  it  is  impossible  for 


Loiiq  apcis  neck. 


TraTJSveyse 
axis  condvlea. 


Fig.  451.— Twist  of  Xeck  in  Congrenitall}-  Dislocated  Femur,  Looking-  from  Above  Downward. 

the  patient  to  walk  normally  with  the  femoral  head  in    the  socket. 
Under  these  circumstances  an  osteotomy  of  the  femur  is  necessary. 

Osteotomy. — When  osteotomy  is  necessary  it  can  be  performed 
by  the  use  of  an  osteotome  or  a  chisel,  dividing  the  femur  beneath  the 
lesser  trochanter  by  a  linear  osteotom)'.  If  this  operation  is  performed 
shortly  after  reduction,  it  will  be  found  that  some  danger  is  incurred  of 
displacing  the  reduced  head  by  the  use  of  the  mallet  and  the  osteo- 
tome. This  danger  can  be  avoided  by  the  division  of  the  femur  a  short 
distance  above  the  condyle,  employing  a  Gigli  saw.  This  is  easily  ac- 
complished by  passing  a  large,  curved  needle  around  the  femur,  care 
being  taken  that  the  needle  should  be  kept  close  to  the  bone  on  the 
inner  side  and  thus  avoid  any  danger  of  injuring  the  artery  or  nerve. 
No  difficulty  will  be  encountered  in  placing  the  wire,  and,  although  the 
skin  and  muscular  tissue  maybe  somewhat  injured  in  dividing  the  bone, 
the  injury  is  no  greater  than  that  met  in  an  ordinary  osteotomy.  It  is 
safer  to  divide  by  the  saw  the  greater  part  of  the  bone,  leaving  a  por- 
tion to  be  broken  that  the  remaining  portion  may  serve  as  a  splint  to 
steady  the  fragments.  The  treatment  after  correcting  the  rotation  by 
rotating  the  foot  outward  is  the  same  as  that  of  an  ordinarv  fracture. 


5o8 


ORTHOPEDIC  SURGERY. 


As  a  guide  to  prevent  the  twisting  of  the  upper  fragment,  a  small  steel 
wire  can  be  driven  into  the  trochanter  during  the  operation.  Any 
twist  of  the  upper  fragment  will  be  readily  noticed. 

Prognosis  After  Treatment. 

The  results  obtained  in  the  treatment  of  congenital  dislocation  of 
the  hip  show  a  gratifying  increase  in  the  percentage  of  permanent  cures 


Fig.  452.— Untreated  Case  of  Double  Congenital  Dislocation.     Unable  to  walk  without 

crutches. 

as  the  knowledge  of  the  pathological  conditions  of  the  deformity  has 
been  more  thoroughly  understood  and  as  technical  skill  has  increased. 

The  results  obtained  at  the  Children's  Hospital  in  the  treatment  of 
congenital  dislocation  of  the  hip  from  1884  to  1903  inclusive  will  serve 
as  a  commentary  on  the  progress  made  in  the  treatment  of  the  affec- 
tion and  will  define  the  prognosis. 

I.  From  1884  to  l8g6—2T  cases.  Treated  by  mechanical  appliances 
without  operation,  7;  by  incision  and  curettage  (Hoffa's  early  opera- 


CONGENITAL  DISLOCATIONS. 


509 


tion),  12;  by  manipulation  under  ether  (Post),  2.     Successful,  o;  un- 
successful, 21. 

II.  FTonil8g6  to  ig02 — ^^  cases.  By  open  incision,  34 :  Successful, 
11;  unsuccessful,  6;  result  unknown,  17.  By  manipulation,  20:  Suc- 
cessful, i;  unsuccessful,  7;  result  unknown,  12. 

III.  Cases  operated  in  ig02 — 22  cases.  By  incision,  2 :  Successful, 
o;  unsuccessful,  2.  By  manipulation,  20:  Successful,  8;  unsuccessful, 
2 ;  relapse,  3  ;  anterior  transposition,  7. 

IV.  Cases  operated  in  IQOJ — JJ  cases.  By  mechanical  stretching 
and  manipulation,  24:  Successful,   16;    unsuccessful,  3;  transposition, 


Fig.  453.— Double  Cong-enital  Dislocation  of  Hip.     Child  aged  four.     Untreated. 

5.     By  manipulation,  8 :  Successful,  6;  unsuccessful,:;  transposition,  i. 
By  incision,  i:  Unsuccessful,  i. 

These  figures  indicate  the  development  of  the  treatment  of  the 
affection  from  the  earlier  attempts  at  treatment  without  operation  until 
the  recognition  of  accepted  methods  of  treatment.  The  results  reported 
as  obtained  in  the  year  1903  were  carefully  examined  by  a  committee 
of  surgeons  six  months  or  a  year  after  operation,  and  may  be  regarded 
as  representing  the  permanent  condition.^ 

^  "Report  of  the  Orthopedic  Staff  of  the  Boston  Children's  Hospital,  Based 
upon  Observations  in  One  Hundred  and  Forty-six  Cases."  Boston  Med.  and 
Surg.  Jour.,  vol.  cli.,  No.  4,  p.  85,  July  28th,  1904. 


5IO  ORTHOPEDIC  SURGERY. 

It  is  difficult  to  determine  from  statistics  the  exact  percentage  of 
success  to  be  expected  from  the  open  incision  and  from  manipulative 
reductions.  Statistics,  however  carefully  compiled,  vary  in  accuracy 
and  in  standards  of  success.  An  examination  of  the  later  statistics 
shows  conclusively  that  the  method  of  reduction  by  operative  manipula- 


FlG.  454.— Same  Patient,  Age  Twenty-eight.     Untreated  case.     Patient  able  to  walk  actively 

with  little  limp. 

tion  (the  so-called  bloodless  reduction)  may  be  expected  to  give  perma- 
nent anatomical  cures  in  from  ten  to  twenty  per  cent  of  the  cases,  and 
improved,  i.e.,  functional  cures,  in  at  least  sixty  per  cent  of  the  cases. 

The  claim  that  a  greater  percentage  of  cures  can  be  obtained  by 
open  incision  carefully  performed  with  the  latest  improvements  in  tech- 


CONGENITAL  DISLOCATIONS. 


511 


niqiie  is  probably  justified,  although  the  results  of  the  earlier  attempts 
at  open  incision  were  not  satisfactory. 

The  statistics  offered  by  Hoffa  of  later  results  from  the  open  incis- 
ion with  improved  technique  are  highly  satisfactory. 

Treatment  of  Older  Adult  Cases.— Baer,  of  Baltimore,  has 
operated  with  success  upon  an  adult  patient  of  twenty-five  years  of  age 
with  double  congenital  dislocation.  The  reduction  was  accomplished 
by  means  of  an  open  incision  with  deepening  of  the  acetabulum.  The 
second  hip  was  operated  upon  two  years  after  the  first.  Although  a 
satisfactory  result  was  obtained  in  this  instance,  such  success  cannot  be 
anticipated  in  a  majority  of  instances,  and  the  risk  of  stiffenino-  the 


Fig.  455.-PIaster-of-Pari.s  Fixation  after  JlanipulatLve  Reduction  of  Double  Dislocation, 
Showing  Amount  of  Ecchymosis. 

joint  is  considerable.  Some  benefit  is  obtained  by  manipulative  treat- 
ment, with  or  without  an  anaesthetic,  in  increasing  the  arc  of  motion 
and  the  usefulness  of  the  limb.  As  a  rule,  however,  the  best  treat- 
ment in  adult  or  older  cases  is  by  gymnastics,  which  will  strengthen  the 
muscles  in  the  lumbar  and  gluteal  regions. 

The  use  of  a  stiffened  corset  holding  the  hips  and  the  dorsal  region 
firmly,  either  made  of  stiffened  leather  or  of  cloth  stiffened  with  steel, 
will  be  found  of  benefit  in  many  of  these  cases  in  furnishing  support  to 
the  back. 

Summary. 

Surgeons  will  vary  somewhat  in  their  choice  of  methods  of  opera- 
tion, according  to  their  experience  and  success  with  the  methods  of 
reduction  by  forcible  manipulation  or  by  open  incision,  but  these  facts 
may  be  said  to  be  generally  accepted : 

As  a  rule  no  attempt  at  reduction  is  advisable  under  two  years  of 
age,  as  the  tissues  are  not  sufficiently  developed  to  prevent  relapse. 

In  the  early  cases,  from  two  to  five  years  of  age,  reduction  is  easily 
accomplished  by  forcible  manipulation. 


512  ORTHOPEDIC  SURGERY. 

In  older  cases,  from  five  to  ten,  except  in  children  with  weak  mus- 
cles, although  reduction  by  forcible  manipulation  is  often  not  difficult, 
reduction  is  much  easier  after  stretching  by  the  Bartlett  machine,  and 
in  some  cases  the  reduction  is  impossible  without  the  aid  of  the  Bart- 
lett machine. 

In  cases  older  than  ten,  as  a  rule,  reduction  by  open  incision  is  to  be 
preferred ;  and  in  resistant  cases  under  ten,  where  there  is  reason  to  be- 
lieve alteration  of  the  shape  of  the  head  and  acetabulum  or  a  firm  and 
narrow  hour-glass  contraction  of  the  capsule  exist,  reduction  by  open  in- 
cision after  a  thorough  stretching  of  the  muscular  tissues  is  advisable. 

In  cases  of  doubt  as  to  which  method  to  employ,  the  surgeon  can 
regard  it  as  a  safe  rule  to  follow  if  reduction  is  first  attempted  by 
forcible  manipulation,  employing  open  incision  if  relapse  follows.  Al- 
though the  operation  by  open  incision  cannot,  if  performed  with  skill,  be 
regarded  as  more  dangerous  than  that  of  forcible  manipulation,  as  a 
rule  it  is  less  acceptable  to  parents  of  patients. 

Where  the  acetabulum  is  too  shallow  to  hold  the  reduced  head,  it 
should  be  deepened  if  a  lasting  reposition  is  to  be  expected,  but  no  sur- 
geon should  attempt  this  procedure  or  the  reduction  by  open  incision 
unless  assured  of  complete  asepsis  in  every  surgical  detail . 

The  length  of  time  needed  in  after-treatment  must  be  determined 
by  the  condition  found  after  reduction,  and  must  be  left  to  individual 
judgment  in  each  case. 

Double  cases  are  to  be  regarded  as  more  than  twice  as  difficult  as 
single.  Attempts  at  reduction  by  forcible  manipulation  should  be  made 
on  both  hips  at  the  same  time,  but  if  open  incision  is  employed,  as  a 
rule  two  separate  operations  are  necessar}". 

KNEE. 

Congenital  dislocation  of  the  knee  is  seen  with  greater  frequency 
than  that  of  some  of  the  other  joints.^  It  occurs  most  often  in  the  form 
of  hyperextension  of  the  leg  on  the  thigh,  which  has  been  considered 
by  some  writers  a  displacement  rather  than  a  true  dislocation  forward. 
In  some  cases  the  lower  epiphysis  of  the  femur  is  bent  forward  on  the 
shaft.-  It  is  in  any  event  a  congenital  affection  of  importance  when  it 
occurs.  It  is  frequently  double,  and  the  displacement  may  be  directly 
forward  or  forward  and  to  one  side.  The  leg  forms  a  right  angle  with 
the  thigh,  the  apex  of  the  angle  being  backward,  and  the  cond)-les  of 
the  femur  can  be  felt  in  the  popliteal  space ;  the  patella  is  often  small 
and  occasionally  absent,  and  lateral  mobility  may  be  present.  Modifi- 
cations in  the  shape  of  the  bone,  ligaments,  and  cartilages  in  the  knee- 

^  Drehman  :  Zeitsch.  f.  orth.  Chir.,  vii..  22  (98  cases). 
-  Delan^lade  :  Rev.  d'Orthopedie,  May,  1903. 


CON  GEN  I TA  L  DISL  O  CA  TIONS. 


5.13 


joint,  even  to  the  point  of  ankylosis,  have  been  recorded  in  some  of 
these  cases.     The  deformity  may  be  associated  with  malformation- of 


Fig.  456.— Congenital  Dislocation  of  the  Knees  Forward  in  a  Yonng  Adult. 

Other  parts,  and  the  cause  can  be  given  no  more  clearly  than  that  of 
other  congenital  deformities. 

Forward  displacement  of  the  leg  at  the  knee  is  to  be  treated  by 
manipulation  in  the  direction  of  correction  and  the  application  of  a 
solint  to  the  knee  to  hold  the  leg  in  a  corrected  position.     Following 


Fig.  457.— Congenital  Dislocation  of  the  Knee.     (Genu  recurvatum  with  club-foot.j 

these  measures  apparatus  should  be  applied  to  limit  the  lateral  motion  if 
it  is  present,  restricting  the  amount  of  hyperextension  and  increasing 
the  amount  of  flexion.     Apparatus  must  be  worn,  of  course,  till  the 
'h'h 


SH 


ORTHOPEDIC  SURGERY. 


structures  about  the  joint  have  adapted  themselves  to  the  new  condi- 
tion. 

Posterior  dislocation  of  the  tibia  on  the  femur  occurs  at  times. 
Lateral  subluxation  may  be  found  in  connection  with  other  congenital 
deformities.^ 

PATELLA. 

Dislocation  of  the  patella  is  among  the  more  common  of  the  con- 
genital dislocations ;  many  cases  reported  as  congenital  have,  however, 
been  doubted. 

The  type  most  frequently  seen  is  outward  dislocation  existing  with 
some  degree  of  knock-knee.     It  may  be  displaced  inward  or  upward,  in 

the  latter  case  being  associated  with 
lengthening  of  the  patella  tendon. 
There  may  be,  in  connection  with 
the  dislocation  outward,  absence  or 
flattening  of  the  outer  condyle  of 
the  femur. 

The  disability  may  be  slight  or 
there  ma}^  be  marked  impairment  of 
the  extension  power  of  the  leg  on 
the  thigh.  Treatment  by  operation 
would  be  similar  to  that  described 
in  speaking  of  slipping  pat-ella. 

Congenital  Absence  of  the 
Patella. - 

The  patella  may  be  absent  or 
tardy  in  its  development.  If  it  is 
absent  the  knee  appears  broad  and 
flat  and  there  may  be  marked  im- 
pairment of  the  function  of  the 
knee.     In  other  cases  the  knee  is 

FIG.  458.-ConKenital  Dislocation  of  bo.h  Knees    ^^^^^^^_      Jt   ^^^y    COCxist    with    Other 

with  Club-foot.     (Remer.)  -' 

malformations  of  the  knee,  espe- 
cially genu  recurvatum.  It  is  often  bilateral  and  is  frequently  associ- 
ated with  club-foot  and  similar  deformities. 

The  treatment  consists  of  apparatus  to  support  the  defective  joint 
and  massasre  and  muscle  trainino;  to  the  extensor  muscles. 


1  Cone  :  Am.  Medicine,  November  5th,  1904,  p.  S12  (with  literature). 
-A.  Thorndike  :  Orth.  Trans.,  vol.  xi. 


CONGENITAL  DISLOCATIONS.  5.15 

ANKLE. 

Inward  and  outward  congenital  dislocations  of  the  ankle  have  been 
recorded  in  connection  with  absence  of  the  tibia  or  fibula.^ 

SHOULDER. 

True  congenital  dislocation  of  this  joint  is  rare,  and  many  cases  re- 
ported as  congenital  have  proved  on  investigation  to  be  dislocations  due 
to  paralysis  or  due  to  injury  to  the  shoulder  at  birth,  resulting  most 
often  in  a  separation  of  the  epiphysis.  The  dislocation  found  is  the 
subspinous,  but  other  varieties  have  been  recorded,  such  as  the  sub- 
coracoid  and  subacromial.  Double  dislocation  of  the  shoulder  has 
been  described  and  in  some  cases  associated  with  other  malformations. 
In  one  case  two  children  in  one  family  were  similarly  affected.  The 
glenoid  cavity  is  likely  to  be  malformed,  as  in  a  case  reported  by  Smith, 
where  there  was  hardly  a  trace  of  the  normal  glenoid  cavity.  In  other 
cases  it  is  approximately  normal.  The  limitation  of  function  is  similar 
to  that  in  traumatic  dislocations.  Cases  of  dislocation  of  the  shoulder- 
joint  in  young  infants  have  been  reduced  with  or  without  incision,  with 
improvement  in  the  usefulness  of  the  arm;  cases  of  true  congenital  dis- 
location, however,  improved  by  operation  are  fev/.  Cases  were  oper- 
ated on  by  Phelps  by  doing  what  was  practically  an  arthrodesis  through 
a  posterior  incision,  and  the  redundant  capsule  was  removed.  Some 
similar  cases  have  been  reported,  but  most  of  them  are  open  to  the  sus- 
picion of  not  having  been  congenital.  The  chances  of  successful  re- 
placement would  be  greater  in  cases  with  a  normal  glenoid  cavity  and 
in  cases  undertaken  early  in  life.  In  later  childhood  the  prospect  is 
less  good. 

In  addition  to  the  operative  reduction,  reduction  by  manipulation  is 
to  be  considered,  following  the  lines  indicated  in  the  operation  for  con- 
genital dislocation  of  the  hip.  After  replacement  the  arm  should  be 
held  by  a  plaster  bandage  for  some  months  in  a  position  of  abduction 
and  outward  rotation." 

ELBOW. 

Congenital  dislocations  of  the  elbow  are  very  rare  and  of  compara- 
tively little  practical  importance.  The  reported  cases  do  not  conform 
to  any  one  type,  following  a  wide  range  of  variation. 

I.  Both  bones  maybe  dislocated  forward  or  backward.  This  condi- 
tion is  extremely  rare. 

'  Freiberg  :  Amer.  Jour,  of  Orth.  Sur. .  vol.  i.,  No.  4,  p.  335. 

-Whitman:  "  Orthopedics,"  second  edition,  p.  473.— Porter:  Orth.  Transac- 
tions, xiii.,  1898.— Cumston:  Amer.  Jour,  of  the  Med.  Sciences,  June,  1903.— Kir- 
misson:  "Traite  des  Mai.  chir.  d'Origine  Congen.,"  Paris,  1898,  p.  485. 


5i6  ORTHOPEDIC  SURGERY. 

2.  The  displacement  of  the  head  of  the  radius  is  a  more  frequent 
form  of  dislocation  and  may  occur  on  both  sides.  The  dislocation  may 
be  backward,  forward,  or  outward,  with  or  without  abnormality  of  the 
other  bones  of  the  arm. 

3.  Backward  dislocation  of  the  radius  and  partial  dislocation  of  the 
ulna  with  imperfect  development  of  the  external  condyle  have  been 
recorded.  The  displacement  may  or  may  not  be  seriously  disabling. 
In  cases  requiring  radical  operation,  the  head  of  the  radius  or  the  entire 
elbow-joint  may  be  resected. 

Cubitus  Valgus— Cubitus  Varus. 

In  connection  with  congenital  dislocation  of  the  elbow  may  be  men- 
tioned a  deviation  from  the  normal  line  of  the  arm  occasionally  seen. 
If  the  arm  of  the  adult  hangs  at  the  side  with  the  palm  of  the  hand 
directed  forward,  the  line  of  the  forearm  should  form  with  the  line  of 
the  arm  an  angle  of  about  169  degrees  with  a  variation  of  10  degrees  in 
either  direction.  The  outward  deviation  of  the  forearm  is  a  few  degrees 
greater  in  women  than  in  men.  Cubitus  valgus  is  the  name  applied  to 
the  condition  in  which  the  forearm  is  displaced  too  far  to  the  radial 
side;  cubitus  varus,  the  condition  in  which  it  is  displaced  to  the  ulnar 
side.  Trauma  is  the  most  frequent  cause  of  the  marked  varieties. 
They  are  also  associated  with  rickets  and  the  element  of  inheritance 
apparently  plays  a  part.  In  case  either  deformity  should  be  severe 
enough  to  require  operative  treatment,  an  osteotomy  may  be  done  simi- 
lar to  the  Macewen  operation  for  knock-knee. 

WRIST. 

Pure  congenital  dislocation  of  the  wrist  is  extremely  rare.  The 
ordinary  form  in  which  it  is  seen  is  in  connection  with  club-hand. 

Spontaneous  Subluxation  of  the  Wrist. 

A  displacement  of  the  wrist  has  been  described  by  Madelung,^  in 
which  the  hand  is  displaced  to  the  palmar  side  of  the  forearm  and  prob- 
ably to  either  the  radial  or  the  ulnar  side  laterally,  generally  to  the  former. 
In  such  cases  the  lower  border  of  the  radius  and  that  of  the  ulna  are 
prominent  at  the  dorsum  of  the  wrist,  and  the  bones  are  somewhat  sep- 
arated from  each  other.  The  wrist  is  much  increased  in  thickness  and 
the  function  of  the  hand  is  impaired.  Active  and  passive  dorsal  flexion 
are  affected  and  some  pain  may  be  present,  especially  in  dorsal  flexion. 
The  hand  can  be  replaced  only  in  the  lighter  grades  of  the  affection. 
There  is  excessive  mobility  of  the  intercarpal  joint  and  there  may  be 
slight  forward  bending  of  the  lower  extremity  of  the  radius. 
'  Archiv  f.  klin.  Chir. ,  Bd.  xxiii. 


CONGENITAL  DISLOCATIONS.  517 

Aside  from  the  pain  which  may  be  present,  the  symptoms  are 
weakness  and  sensations  of  discomfort  about"  the  wrist.  The  causes  of 
the  affection  are  given  as  relaxation  of  the  Hgaments,  stretching  of  the 
muscles  by  hard  work,  irregularity  of  growth  at  the  lower  end  of  the 
radius,  and  possibly  a  malposition  lasting  over  from  rickets.  The  treat- 
ment is  at  first  hyperextension  of  the  joint  by  means  of  bandages  and 
splints,  the  use  of  massage  and  similar  measures,  and  osteotomy  in 
cases  with  bony  deformity  sufficient  to  require  it. 


CHAPTER    XIX. 
TALIPES. 

Talipes  equino-varus  (Club-foot).  —  (Pathology. —  Etiolog}-. —  Symptoms. —  Diag- 
nosis.— Prognosis. — Treatment. ) — Talipes  equinus  (Varieties. — Etiology. — 
Pathology.  —  Symptoms.  — Treatment).  — Talipes  calcaneus  (Varieties.  — 
Symptoms. — Treatment). — Talipes  valgus. — Talipes  varus. ^Talipes  cavus. 

Club-hand  (Varieties. — Etiology.  —  Symptoms. — Diagnosis. — Treatment). 

The  name  talipes  signifies  a  deformity  of  the  foot,  and,  although  it 
was  originally  used  to  indicate  a  form  of  talipes  now  known  as  equino- 
varus  or  club-foot,  the  present  use  of  this  word  is  as  a  prefix  to  the  de- 
scriptive adjective  designating  the  variety  of  the  deformity  which  exists. 
Of  the  pure  forms  of  talijDes  one  finds  described  talipes  equinus,  the 
plantar-flexed  foot ;  talipes  calcaneus,  the  dorsally  flexed  foot ;  talipes 
cavus,  the  foot  with  increased  arch;  talipes  valgus,  the  everted  foot; 
and  talipes  varus,  the  inverted  foot. 

Talipes  equinus  may  exist  with  either  valgus  or  varus,  being  then 
spoken  of  as  equino-valgus  or  equino-varus,  the  elements  of  two  de- 
formities being  present.  Talipes  calcaneus  may  exist  in  connection 
with  valgus  or  very  rarely  with  varus,  being  then  known  as  calcaneo- 
valgus  or  calcaneo-varus. 

TALIPES    EQUINO-VARUS    (CLUB-FOOT). 

The  term  club-foot  is  popularly  applied  to  a  deformity  characterized 
by  an  inversion,  torsion,  and  depression  of  the  front  part  of  the  foot 
with  an  elevation  of  the  heel. 

In  walking  on  a  foot  thus  deformed,  the  weight  of  the  body  is  borne, 
not  by  the  sole  of  the  foot,  but  by  the  outer  side,  and  in  extreme  cases 
by  the  dorsum  of  the  foot. 

The  distortion  is  also  known  as  "reel"  foot  —  pes  contortus, 
Klump-Fuss,  pied  bot,  etc. 

The  deformity  is  either  congenital  or  acquired. 

Frequency. — Club-foot  is  by  no  means  an  uncommon  distortion, 
and  was  mentioned  in  literature  even  in  the  days  of  Homer. ^  In  6,969 
orthopedic  patients  applying  at  the  out-patient  department  of  the  Chil- 
dren's Hospital,  Boston,  there  were  488  cases  of  club-foot.  Congenital 
club-foot  is  by  far  the  most  frequent  of  the  congenital  deformities  of 

'"Iliad,"  i,,  599;  xxi.,  331. 
518 


TALIPES. 


519 


the  foot.  It  affects  males  more  frequently  than  females,  and  the  right 
foot  is  more  frequently  affected  than  the  left.  It  is  as  often  double  as 
single.  Acquired  club-foot  affects  males  and  females  in  about  equal 
proportion,  the  right  foot  is  most  often  affected,  and  it  is  more  fre- 


FIG.  459. 


-Section  of  Foot  and  Leg 
in  Club-foot. 


Fig.  460. — Section  of  Foot  and  Leg, 
Normal. 


quently  unilateral  than  bilateral.  Chaussieur,  among  22,923  newly 
born  infants,  reports  37  cases  of  club-foot.  Lannelongue,  among 
15,229  births  at  the  Paris  Maternity  Hospital,  found  8  cases. 

Pathology. — The  deformity  is  a  dislocation  inward  of  the  anterior 
part  of  the  foot,  the  dislocation  taking  place  at  the  medio-tarsal  articu- 
lation. All  the  tissues  are  necessarily  affected  by  the  abnormal  posi- 
tion, and  the  skin,  muscles,  tendons,  and  fasciae  are  all  altered. 

In  all  cases  of  congenital  club-foot,  even  in  that  of  a  full-term  foe- 
tus, the  scaphoid  bone  will  be  found  articulating  with  the  side  of  the 


Fig.  461.— Relation  of  Astragalus  to  Os 
Calcis.     (Whitman.) 


Fig.  462.— Relation  of  Astragalus  to  Os 
Calcis  in  Flat-foot.    (Whitman.) 


head  of  the  astragalus  rather  than  with  the  anterior  surface.  The 
articulation  is  also  more  toward  the  under  side  of  the  astragalus,  the 
head  of  which  is  thus  uncovered. 

The  scaphoid  may  be  so  far  distorted  to  the  side  as  to  articulate  at 
one  end  with  the  tip  of  the  internal  malleolus.  The  cuneiform  bones, 
being  intimately  connected  with  the  scaphoid,  follow  the  displacement 
of  the  latter,  and  the  same  is  true  of  the  metatarsal  bones  and  the  pha- 


520 


ORTHOPEDIC  SURGERY. 


langes,  so  that  the  long  axis  of  the  front  of  the  foot  forms  a  right  angle, 
or  even  an  acute  angle,  with  the  axis  of  the  leg.  The  cuboid  is  neces- 
sarily displaced  to  the  inner  side  and  does  not  articulate  with  the  front  of 
the  OS  calcis,  the  facet  of  which  also  inclines  obliquely  to  the  inner  side. 

In  fully  developed  cases,  and  in  older  children  or  adults,  there  is  a 
more  marked  and  important  alteration  in  the  shape  of  the  bones. 

The  OS  calcis,  by  the  elevation  of  the  tuberosity,  is  drawn  from  a 
horizontal  into  a  position  approaching  the  vertical.  It  is  also  more  or 
less  rotated  on  its  vertical  axis,  so  that  its  anterior  extremity  is  directed 
outward  and  the  posterior  extremity  inward,  and  thus  the  anterior  artic- 
ulating facet  is  oblique  to  the  axis  of  the  bone.    The  cuboid  bone  main- 


FiG.  463. — Dissection  of  Club-foot. 


tains  its  connection  with  the  os  calcis,  but  follows  the  inward  direction 
of  the  anterior  extremity  of  the  foot. 

There  is  no  rotation  of  the  astragalus  on  the  vertical  axis,  but,  as 
has  been  stated,  it  is  depressed  forward  on  its  horizontal  axis,  so  that 
only  the  posterior  portion  of  its  superior  articular  surface  is  in  contact 
with  the  inferior  articular  surface  of  the  tibia,  and  the  anterior  part  of 
its  anterior  facet  projects  beneath  the  skin  of  the  dorsum  of  the  foot. 
Besides  this  displacement,  the  shape  of  the  bone  is  altered  by  the 
twisting  inward  of  the  head  and  neck,  so  that  the  anterior  articular  sur- 
face looks  inward  instead  of  forward,  and  the  disposition  of  the  carti- 
lage at  the  articulating  surfaces  of  the  head  of  the  astragalus  is  neces- 
sarily altered.  The  three  cuneiform  and  the  three  metatarsal  bones, 
being  closely  connected  with  the  scaphoid,  are  more  twisted  to  the  in- 
side than  is  the  case  with  the  cuboid,  though  the  metatarsals  are  not  all 


TALIPES. 


521 


equally  involved  in  the  rotation  from  without  inward  and  are  spread  out 
something  as  the  branches  of  a  fan,  in  such  a  way  that  the  anterior  part 
of  the  foot  is  enlarged  more  than  normal.  Besides  these  alterations  in 
the  position  of  the  foot  others  take  place  secondarily,  depending  on 
pressure  and  the  effect  of  locomotion  on  the  distorted  bones. 

The  different  tendons  assume  an  abnormal  direction  and  in  general 
are  carried  farther  to  the  inside  than  is  normal ;  this  is  especially  true 
of  the  tibialis  anticus,  the  common  extensor  of  the  toes,  and  the  long 
extensor  of  the  great  toe.     Synovial  bursse  may  form  on  the  outer 


Fig.  464.  — Double  Congenital  Club-foot. 


edge  and  back  of  the  foot,  which  may  become  inflamed  and  suppurate ; 
corns  and  callosities  are  also  formed  on  the  skin,  from  the  pressure  of 
walking.  No  change  has  been  found  in  the  nerves  or  the  spinal  cord  in 
cases  of  club-foot. 

In  extreme  cases  there  may  be  slight  alteration  in  the  shape  of  the 
femur  and  a  laxity  at  the  knee-joint;  the  tibia  has  also  been  found  al- 
tered, and  the  same  is  true  of  the  fasciae.  The  muscles  are  never  found 
paralyzed  in  congenital  club-foot,  but  the  contracted  muscles  seem  more 
developed  than  the  lengthened  muscles.  The  muscles  of  the  leg  atro- 
phy from  disuse,  and  the  leg  is  much  smaller  and  the  foot  shorter  than 
normal. 


522  ORTHOPEDIC  SURGERY. 

In  addition  to  the  faulty  shape  of  the  bones  there  is  a  change  in  the 
ligaments  and  fasciae,  and  this  is  not  confined  to  the  severe  and  most 
inveterate  cases,  but  is  always  present.  Not  only  are  the  plantar  liga- 
ments and  fasciae  contracted,  but  the  internal  lateral  and  posterior  liga- 
ments are  also  contracted. 

Etiology. — In  regard  to  the  etiology  of  congenital  club-foot,  various 
theories  have  been  advanced  in  explanation  of  the  deformity. 

A  popular  idea  is  that  the  distortion  is  due  to  maternal  impressions, 
but  no  conclusive  evidence  in  regard  to  this  has  been  obtained.^ 

Heredity,  on  the  part  of  both  the  father  and  mother,  has  been 
established  without  doubt  in  a  certain  number  of  cases,  but  in  a  very 
large  majority  no  trace  of  similar  deformity  in  ancestors  can  be  found. 

The  chief  theories  which  have  been  advocated  to  explain  the  de- 
formity in  uterine  life  are  as  follows : 

First. — Abnormal  compression  in  the  uterine  cavity. 

Second. — Retraction  or  paralysis  of  muscles  depending  or  not  on 
lesion  of  the  nervous  system  occurring  in  utero. 

Third. — A  malformation  depending  upon  arrest  of  development  of 
the  foot. 

With  regard  to  these  theories  it  may  be  said  that  abnormal  com- 
pression of  the  uterine  walls  may  be  a  factor  in  producing  the  deformity, 
that  evidence  of  muscular  paralysis  is  wanting,  and  that  the  evidence 
that  club-foot  is  due  to  a  retarded  rotation  of  the  foot  -  and  is  the  persis- 
tence of  a  foetal  condition  is  not  supported  by  good  evidence.' 

It  may  be  said  that  we  are  entirely  ignorant  of  the  causation  of 
club-foot,  and  unable  to  give  a  reasonably  satisfactory  explanation  of 
the  phenomena  of  its  development." 

Symptoms. — Club-foot  gives  rise  to  great  inconvenience  in  walking. 
In  uncorrected  cases,  however,  the  amount  of  skill  and  agility  patients 
acquire  in  locomotion  is  surprising,  even  though  the  deformity  remains 
unchanged.  Bursae  and  callosities  form  over  the  unprotected  portions 
of  the  foot,  and  may  inflame  and  cause  much  discomfort,  limiting  the 
amount  of  the  patient's  activity.  A  laxity  of  the  knee-joint  is  some- 
times developed  in  consequence  of  club-foot. 

The  gait  of  these  patients  is  characteristic.  In  double  cases  the 
feet  are  lifted  one  over  the  other  as  a  step  is  taken,  giving  a  peculiar 
appearance,  and  perhaps  suggesting  the  popular  name  of  "reel"  feet. 
The  tendo  Achillis  is  firm  and  hard  to  the  touch ;  the  plantar  fascia 

'  Dabney  :  '"  Cyclopedia  of  Diseases  of  Children,"  vol.  i. 

-Brit.  Med.  Journ.,  1886,  ii.  10;  Archives  of  Med.,  New  York,  Dec.  i,  1882; 
Boston  Med.  and  Surg.  Journ.,  Oct.  27,  1887.— Wolff :  "  Ueber  die  Ursachen,  etc.. 
des  Klumpfusses,"  Berlin,  1903. 

^Bessel  Hagen  :  "  Die  Path,  und  Therap.  des  Klumpfusses,"  Heidelberg,  1899. 

■*R.  W.  Parker  and  Shattuck  :  Brit.  Med.  Jour.,  May  24th,  1SS4.  p.  998. 


TALIPES.  523 

will  be  found  short  and  hard  on  palpation.  The  front  of  the  foot  pro- 
jects to  the  inside  of  the  vertical  axis  of  the  leg,  the  posterior  end  of 
the  OS  calcis  is  raised  and  turned  inward,  the  leg  is  turned  outward, 
and  the  head  of  the  astragalus  and  cuboid  project  under  the  skin. 
There  is  usually  atrophy  of  the  muscles  of  the  leg.     The  external  mal- 


FlG.  465. — Cong'enital  Club-foot.  Cured  club.  Twenty-four  years  after  correction  in  infancy 
by  tenotomy,  manual  force  and  retention,  walking  appliance  worn  for  two  j'ears.  Patient 
able  to  walk  without  limp  or  discomfort  twenty  miles  a  day. 

leolus  is  prominent  and  the  internal  malleolus  not  readily  felt.  The 
foot  is  more  or  less  rigid  in  the  deformed  position,  resisting  gentle 
attempts  at  correction. 

Diagnosis. — There  is  no  difficulty  in  recognizing  the  deformity  of 
club-foot.  In  infancy,  a  true  club-foot  is  sometimes  thought  to  exist 
when  the  trouble  is  simply  a  temporary  spasm  of  the  tibialis  muscles 
which  turn  the  foot  in.  This  passes  away  in  a  short  time  and  should 
occasion  no  anxiety. 

The  history  of  the  case  establishes  a  diagnosis  between  the  congeni- 
tal and  non-congenital  forms  of  club-foot.     The  paralytic  form  can  be 


524 


ORTHOPEDIC  SURGERY. 


recognized  by  the  evidence  of  paralysis  of  the  muscles  on  the  anterior 
and  external  surface  of  the  leg.  Paral)  sis,  it  may  be  added,  is  the  only 
common  cause  of  acquired  club-foot.  The  severity  of  cases  of  club- 
foot cannot  be  determined  always  by  the  apparent  distortion.  Cases 
resembling  each  other  in  outward  appearance  may  pro\'e  less  or  more 
difficult  of  treatment.  As  a  rule,  however,  it  may  be  said  that  the 
younger  the  patient  the  less  resistant  the  deformity,  and  it  is  often  con- 
venient to  consider  the  cases  as : 

I  St.  Infantile — i.e.,  infants  in  arms. 

2d.  Walking  cases — i.e.,  cases  in  young  children  in  which  the  feet 
have  been  walked  upon  before  the  deformity  has  been  corrected. 


Fig  466. 


Fig  467. 


Fig.  468. 


Fig.  466.— Diagram  Indicating-  Mid-tarsal  Articulation  in  Club-foot  and  the  alteration  in  the 

positions  of  the  sci.phoid  and  cuboid  in  their  relation  to  the  astragalus  and  os  calcis— with 

alteration  in  the  shape  of  front  of  os  calcis. 
Fig.  467.— Diagram  of  a  Normal  Foot. 
Fig.  468.— Diagram  of  a  Club-foot  Partially  Corrected,  Leaving  the  Projection  of  Front  of  Os 

Calcis  Unchanged,  and  the  Consequent  Imperfect  Reduction  of  the  Cuboid.     A  relapse 

necessarily  follows. 

3d.  Resistant  or  relapsed  cases — i.e.,  those  which  have  resisted 
treatment,  or  in  which  treatment  has  been  inefficient,  and  in  which  the 
deformity  has  recurred. 

4th.  Neglected  cases,  in  which  the  feet  have  grown  for  years  in  a 
severely  distorted  position. 

Prognosis. — In  regard  to  the  prognosis  of  the  deformity,  it  may  be 
said  that  the  distortion  does  not  correct  itself,  and,  if  left  uncorrectea, 
remains  the  most  obstinate  of  malformations.  The  deformity  is  one 
which  is  essentially  curable;  in  fact,  it  may  be  said  that  it  is  always 
curable,  provided  care  and  attention  can  be  given  by  both  surgeon  and 
nurse. 


TALIPES.  525 

The  amount  of  time  needed  for  treatment  varies  according  to  the 
method  employed.  Formerly  much  time  was  needed  in  the  treatment 
of  inveterate  cases,  but  since  the  introduction  of  open  incision  and  tarsal 
resection,  when  necessary,  correction  can  be  accomplished  in  a  short 

time. 

In  infantile  cases  the  time  required  for  correction  is  relatively  short, 
but  retentive  appliances  are  needed  for  a  longer  time.  It  may  be  said 
in  general  that  the  older  the  cases  and  the  larger  the  foot  the  more 
difficult  the  correction,  but  the  less  the  danger  of  relapse  after  correc- 
tion. 

In  regard  to  the  permanence  of  the  cure  and  the  danger  of  relapse, 
it  may  be  said  that  if  perfect  correction  is  attained  relapse  is  excep- 
tional, if  moderate  care  is  used  in  the  employment  for  a  sufficient  time 
of  retentive  appliance.' 

But  it  must  be  borne  in  mind,  especially  in  the  case  of  young  chil- 
dren, not  only  that  the  correction  must  be  complete,  but  that  efficient 
appliances  for  keeping  the  proper  position  of  the  foot  in  walking  (reten- 
tive or  walking  appliances  to  be  described)  must  be  worn  until  the  gait 
and  attitude  are  perfect.  In  club-foot  half-cures  are  practically  no 
cures.     Relapsed  cases  are  invariably  resistant  and  difficult  to  correct. 

Treatment.— The  object  of  treatment  is  the  correction  of  the  distor- 
tion and  the  retention  of  the  foot  in  a  corrected  position  until  any  re- 
turn of  the  deformity  is  impossible,  the  tendency  to  relapse  being  very 

strong. 

The  treatment  should  be  purely  mechanical,  or  both  operative  and 

mechanical. 

The  treatment  of  club-foot,  therefore,  requires : 

1.  A  rectification  of  the  misplaced  bones  and  a  lengthening  of  short- 
ened and  contracted  tissues. 

2.  A  retention  in  a  normal  position  until  the  abnormal  facet  of  the 
astragalus  and  the  other  tissues  become,  under  the  pressure  of  new  po- 
sition, normal. 

At  the  present  time  few  procedures  in  surgery  are  as  precise  in  their 
indications  and  as  certain  in  their  results  as  the  methods  for  the  cor- 
recting of  club-foot. 

The  correction  of  club-foot  should  be  divided  into  two  steps,  whether 
the  treatment  is  mechanical  or  operative. 

I  St.  Correction  of  the  varus  deformity. 

2d.  Correction  of  the  equinus  deformity. 

In  other  words,  the  front  of  the  foot  should  be  twisted  out  and  after- 
ward be  raised.  This  will  be  found  of  practical  importance,  as  the  foot 
is  more  easily  twisted  before  than  after  the  equinus  deformity  is  over- 
come. 

1  Trans.  Am.  Orthop.  Assn.,  vol.  i.,  "  Club-foot." 


526 


ORTHOPEDIC  SURGERY. 


.  Operative  treatment  in  some  form  is  the  method  to  be  selected  in 
cases  of  congenital  club-foot,  except  in  young  infants  and  in  older  chil- 
dren when  some  contraindication  to  operation  exists. 

The  mechanical  procedures  for  correcting  club-foot  are  as  follows : 

Manual  manipulation. 

Plaster-of-Paris  bandages. 

Apparatus. 

The  operative  procedures  which  are  to  be  considered  in  treating 
club-foot  are : 

Tenotomy. 

Division  of  the  ligaments. 

Open  incision. 

Forcible  correction  and  osteotomy. 

Mechanical  Correction. 

Manual. — The  simplest  method  of  correction  is  by  the  use  of  the 
hands,  and  in  the  case  of  a  new-born  infant  with  club-feet  the  mother 
may  be  directed  to  manipulate  the  foot,  and  having  rectified  the  de- 


FiG.  469. — Double  Club-foot  in  Plaster  Bandages  After  Operative  Correction. 

formity  by  gentle  force  several  times  daily,  to  hold  it  as  straight  as 
possible  for  a  minute  or  two  each  time.  This  process  continued  daily 
over  a  period  of  months  is  in  intelligent  hands  capable  of  restoring  the 
foot  to  its  normal  mobility  and  position,  after  which  retention  treat- 
ment should  be  besfun. 


TALIPES. 


527 


Plaster-of-Pai  is  Bandages. — Another  method  in  correcting  club-foot 
is  by  repeated  fixation  in  a  plaster-of-Paris  bandage,  the  foot  being  held 
as  nearly  in  a  corrected  position  as  possible  at  each  application  of  the 
bandage  until  the  bandage  hardens.  The  application  of  a  plaster-of- 
Paris  bandage  must,  however,  be  made  with  care  and  skill  to  prove  effi- 
cient, whether  applied  for  correction 
without  operation  or  to  maintain  the 
overcorrected  position  obtained  by  op- 
eration. 

The    foot    should    be    wound    with 
plenty  of  sheet  wadding,  pads  should  be 


Fig.  470. — Congenilal  Double  Club- 
foot Walking  Before  Operation. 


Fig.  471. —Double  Club-foot.  Two  months  after  correction 
b}'-  forcible  manipulation,  wearing  walking  retentive 
appliances.     Same  case  as  Fig.  470. 


placed  between  the  toes,  and  the  foot  should  be  held  overcorrected 
from  the  first  during  the  application  of  the  bandage  by  an  assistant, 
who  shifts  the  fingers  from  place  to  place  to  keep  out  of  the  way  of  the 
bandage,  yet  who  maintains  the  overcorrection.  To  overcorrect  the 
position  of  the  foot  when  the  plaster,  is  setting  is  to  cause  folds  of  the 
bandage  to  turn  in  and  either  compress  or  cut  the  tissues  after  the  plas- 
ter is  set.  It  is  important  to  keep  the  inner  end  of  the  foot  part  of  the 
bandage  long,  to  press  outward  the  front  of  the  foot,  and  thus  antago- 
nize the  varus. 


528 


OR  THOPEDIC  S  UR  GER 1 '. 


The  circulation  of  the  toes  must  be  carefully  watched  after  the  ap- 
plication ©f  such  a  bandage. 

An  extension  of  this  method  is  to  be  obtained  after  the  plaster  has 
set  by  removing  an  elliptical  piece  of  the  plaster  bandage  over  the  an- 
terior and  outer  aspect  of  the  ankle  and  dividing  the  rest  of  the  band- 
age at  the  same  level  by  a  circular  cut.  By  crowding  the  front  of  the 
foot-piece  up  and  out  and  holding  it  in  the  improved  position  by  fresh 
bandages  applied  over  the  old  plaster,  further  correction  is  obtainable. 


Fig.  472. — Splints  for  Equino-varus  Applied. 

The  bandage  should  reach  above  the  knee,  where  the  limb  should 
be  slightly  bent  to  prevent  the  plaster  bandage  (which  should  be  re- 
newed ever}'  two  or  three  weeks)  from  rolling  around  the  limb,  and  to 
prevent  the  child  from  kicking  it  off.  In  the  case  of  small  children 
with  plump  legs,  and  in  resistant  cases,  it  will,  however,  be  found  diffi- 
cult to  prevent  the  heel  from  being  drawn  away  from  the  bandage,  and 
stretching  of  the  tendo  Achillis  will  by  this  method  be  tedious. 

This  method  has  the  disadvantage  of  being  tiresome,  but  it  has 
many  advantages  in  being  a  practical  method,  readily  applied,  and  not 
leaving  details  of  application  to  the  patient's  parents.     It  is  evident  that 


TALIPES.  529 

correction  in  this  way,  if  persistently  applied,  is  possible,  but,  except  in 
very  young  children,  it  is  advisable  to  perform  tenotomy  first.  If  the 
Chinese^  can  produce  an  extreme  deformity  by  bandaging  the  children's 
feet,  the  same  method  could  be  emploved  for  the  correction  of  deform- 
ity. 

^^^/^m/z/j.— Mechanical  correction  fwithout  tenotomy)  by  means 
of  appliances  has  been  successfully  employed  in  very  young  cases. 
The  method,  however,  requires  much  persistence  on  the  part  of  the 
surgeon  if  a  perfect  cure  is  expected,  and  is  not  to  be  advised. 

Although  treatment  by  apparatus  is  not  sufficiently  effective  to  cure 
any  but  the  mildest  forms  of  congenital  club-foot  in  young  children,  it 
is  often  enough  to  bring  about  a  cure  in  acquired  club-foot  of  moderate 
severity.  The  form  of  apparatus  is  the  same  whether  used  as  a  correc- 
tive or  as  a  retentive  appliance,  and  will  be  described  here.  The  object 
of  such  apparatus  is  to  retain  the  tarsal  bones  in  proper  position  until 
the  muscles  and  ligaments  have  adapted  themselves  to  the  normal  posi- 


FIG.  473.-Taylor  Shoe  in  Process  of  Adjust-  FiG.  474.-The  Upright  Brought  into  Place 

inent.     The  sole  plate  applied  and  the  foot  and  Acting  as  a  Lever,  Turning  the  Foot 

strapped  to  the  sole  plate.  to  the  Outer  Side. 

tion,  and  until  articular  facets  have  been  formed  in  the  proper  directior, 
or  the  astragalus  and  os  calcis  have  assumed,  under  altered  pressure,  a 
relatively  normal  shape. 

Corrective  apparatus  is  essential  after  the  desired  position  of  the 
foot  has  been  obtained  by  other  means. 

The  corrected  foot  tends  to  relapse  in  two  directions— inversion  and 
elevation  of  the  heel.  If  this  is  unchecked  and  walking  is  done  in  im- 
proper attitudes,  hurtful  pressure  and  strain  fall  upon  the  bones  and 
ligaments  of  the  foot,  and  relapse  takes  place.  This  should  not  occur 
if  proper  retention  and  walking  with  a  proper  attitude  of  the  foot  are 
cared  for. 

As  these  appliances  are  to  be  worn  a  long  time,  they  should  be  light, 
readily  adjusted  by  the  nurse,  not  unsightly,  and  m  no  way  limiting  lo- 
comotion, walking,  or  running.     The  best  are  worn  within  the  shoe. 

'  Percy  Brown  :  Journal  of  Med.  Research.  1904. 

34 


530  ORTHOPEDIC  SURGERY. 

It  is  unnecessary  to  describe  all  the  various  appliances  that  have 
been  used.  Mention  will  here  be  made  of  one  which  has  been  found  of 
service  in  the  writers'  experience,  after  a  careful  trial  of  the  usual  \'ari- 
eties  of  appliances  designed  for  the  purpose. 

It  is  to  be  remembered  that  in  all  appliances  it  is  necessary  that  the 
pressure  preventing  a  faulty  position  of  the  foot  should  be  applied  pre- 
cisely, pressing  the  front  of  the  foot  and  tip  of  the  heel  outward,  the 
front  of  the  foot,  especially  the  outer  edge  including  the  cuboid,  upward, 
and  the  back  of  the  foot,  i.e.,  the  end  of  the  os  calcis,  downward,  and 
the  outer  dorsum  of  the  foot  inward. 

Inward  pressure  should  be  exerted  upon  the  outer  edge  of  the  front 
of  the  OS  calcis  and  astragalus,  and  not  upon  the  cuboid,  as  is  too  com- 
monly done  in  inefficient  apparatus.  As  the  latter  bone  is  in  front  of 
the  mediotarsal  joint,  inward  pressure  upon  it  not  only  fails  to  correct 
the  deformity  but  tends  to  increase  it.  This  explains  the  occurrence  of 
many  relapses. 

The  apparatus  (Chapter  XXI.,  27),  which  is  a  modification  of  Tay- 
lor's varus  shoe,  consists  of  a  sole  plate  small  enough  to  fit  in  a  shoe 
secured  to  a  jointed  upright  furnished  with  a  stop  to  prevent  the  plate 
from  dropping  into  the  equinus  position.  The  foot  is  secured  to  the 
plate  by  means  of  a  strap  which,  secured  to  the  inner  side  of  the  plate, 
passes  from  the  inside  of  the  great  toe  obliquel)-  to  the  outside  of  the 
foot  so  as  to  press  upon  the  anterior  outer  surface  of  the  os  calcis  and 
through  a  loop  at  the  outside,  and  then  is  brought  across  the  ankle 
through  the  metal  loop  and  secured  in  the  clasp.  A  cross  strap  to 
keep  the  toes  down,  and  a  cross  ankle  strap  to  keep  the  heel  down,  are 
sometinies  necessary  in  addition,  with  a  back  strap  behind  the  heel. 

The  appliance  can  be  worn  inside  of  a  shoe,  opened  like  a  bicycle 
shoe  well  down  to  the  toes. 

A  combination  of  operative  and  mechanical  methods  of  treatment  is 
at  present  the  most  common  mode  of  treating  club-foot  at  all  ages. 
The -operative  interference  most  frequently  resorted  to  is  tenotomy  and 
subcutaneous  division  of  the  fasciae  or  ligaments. 

Operative  Tre.\tment. —  Tenotomy. —  The  structures  to  be  di- 
vided are,  of  course,  those  which  hold  the  foot  in  its  deformed  position. 
The  tendons  may  be  divided  by  entering  the  tenotome  under  the 
skin  and  cutting  the  tendon  from  without  inward,  or  by  passing  the 
tenotome  under  the  tendon  and  cutting  outward.  The  advantage  of 
the  former  is  that  there  is  no  danger  of  making  a  large  skin  incision  by 
a  slip  of  the  tenotome.  There  is,  however,  danger  of  incomplete  cut- 
ting of  the  tendon.  The  tendon  which  is  most  frequently  divided  in 
equino-varus  is  the  tendo  Achillis. 

Section  of  the  Tendo  Achillis.— The  patient  should  lie  upon  his  face 
or  side  and  an  assistant  should  bold  the  foot ;  the  surgeon  enters  the 


TALIPES. 


531 


knife  parallel  to  the  border  of  the  tendon,  passing  the  tenotome  flatwise 
between  the  tendon  and  the  skin.  This  having  been  done,  the  blade  of 
the  knife  is  turned  toward  the  posterior  surface  of  the  tendon  and  the 
assistant  raises  the  end  of  the  foot  so  as  to  stretch  the  tendo  Achillis 
slightly.  The  left  index  finger  presses  on  the  skin  over  the  back  of  the 
tenotome,  and  in  this  way  the  sensation  of  the  cutting  of  the  tendon 
can  be  felt. 

The  only  precaution  necessary  is  to  be  assured  that  the  tendon  is 
completely  divided.  When  the  operation  is  done,  the  extravasated  blood 
IS  squeezed  out  of  the  opening  and  a  small  amount  of  aseptic  gauze  is 
placed  over  the  wound.  The  operation  should  be  done  aseptically  and 
an  aseptic  dressing  applied. 

Section  of  the  Tibialis  Posticus. -S^zWoxx  of  the  tibialis  posticus  is 
done  m  the  following  way:  If  the  muscle  is  divided  in  the  leg  the  foot 
IS  placed  on  its  external  border.     The  surgeon  divides  the'  skin  by 


^'*5-  475.  Fig.  476. 

Fig.  476.— Imprint  of  Normal  Foot. 

means  of  a  pointed  tenotome  2  cm.  above  the  tip  of  the  internal  malle- 
olus and  on  a  vertical  line  situated  half-way  between  the  posterior  bor- 
der of  the  malleolus  and  the  corresponding  border  of  the  tendo  Achillis 
The  tenotome  should  be  directed  perpendicularly  downward  to  the 
depth  of  I  or  1.5  cm.  Then  the  handle  of  the  instrument  should  be 
turned  so  as  to  describe  the  arc  of  a  circle  and  the  tendon  divided  ver- 


532 


ORTHOPEDIC  SURGERY. 


tically  inward.  The  assistant  at  the  same  time  turns  the  foot  forcibly 
in  the  direction  of  abduction.  If  the  incision  is  made  too  near  the  mal- 
leolus, the  internal  saphenous  vein  and  nerve  may  be  cut.  If  the  inci- 
sion is  made  too  near  the  tendo  Achillis,  there  is  danger  of  dividing  the 
tendon  of  the  long  flexors  of  the  toes  and  the  posterior  tibial  artery  and 

nerve. 

The  writers  can  record  the  puncture  of  the  posterior  tibial  artery 
by  the  point  of  a  tenotome  and  the  formation  of  a  small  aneurism  which 
required  ligation,  but  caused  no  subsequent  annoyance. 

The  Tendon  of  the  Tibialis  Anttcus.—ThQ  tendon  of  the  tibialis  an- 
ticus  is  divided  more  easily.     For  this  purpose  it  is  sufficient  to  be 


Fig.  477.-Relapsed  Resistant  Congenital  Club-foot  in  a  Boy  of  Eight.     Front  view. 


guided  by  the  prominence  of  the  tendon  put  on  a  stretch  by  abducting 
the  foot.  To  avoid  the  wounding  of  the  deep  parts,  it  is  better  to  enter 
the  tenotome  under  the  tendon. 

Division  of  the  Plantar  Fascia.— \X.  is  often  necessary  to  divide  also 
the  plantar  fascia,  preferably  before  division  of  the  tendo  Achillis,  as 
the  latter  acts  as  a  means  of  support  for  stretching  the  foot  when  the 
plantar  fascia  is  divided.     The  plantar  fascia  is  divided  in  the  same  way 


TALIPES. 


533 


that  the  tendons  are  incised.  The  most  prominent  portion  of  the  fas- 
cia is  the  point  of  election  for  subcutaneous  incision.  The  fascia,  it 
must  be  borne  in  mind,  is  not  a  narrow  band,  but  a  broad  Hgament 
needing  a  long  subcutaneous  incision.  The  tenotome  should  be  inserted 
on  the  inner  side  of  the  sole  nearly  half-way  between  the  os  calcis  and 
the  ball  of  the  foot,  but  nearer  to  the  os  calcis.  The  tenotome  is  to  be 
pushed  subcutaneously  nearly  across  the  sole,  the  edge  of  the  knife 


Fig.  47S.-  Same  Case.     Three  weeks  after  forcible  correction,  immediately  after  removal  of 

plaster  retention  bandages. 

turned  toward  the  fascia,  and  the  knife  drawn  across  the  fascia,  which 
will  be  felt  to  give  way  as  it  is  divided ;  an  assistant  should  make  up- 
ward pressure  upon  the  ball  of  the  foot,  in  order  to  put  the  fascia  on 
the  stretch.  As  the  artery  lies  deeply,  there  is  no  danger  of  injuring 
it,  if  ordinary  care  is  used. 

The  tenotomes  used  should  be  strong  at  the  neck,  and  the  cutting 
edge  should  not  be  too  long,  as  the  skin  is  necessarily  divided  if  they 
are  too  long ;  infantile  cases  require  a  much  smaller  instrument.  The 
blunt-pointed  tenotome  is  but  little  used  now,  and  the  sharp-pointed 
ones  are  used  for  all  subcutaneous  work. 

Tenotomes  as  furnished  by  instrument-makers  are  ordinarily  much 
too  large,  and  though  serviceable  in  myotomy,  are  better  for  tenotomy 
in  children  if  smaller. 

The  Repair  of  Divided  Tendons}— ^]\q\\  a  tendon  is  divided,  the 
^Seggel:  Beitr.  z.  klin.  Chir.,  xxxvii.,  i  and  2. 


534 


ORTHOPEDIC  SURGERY. 


cut  ends  are  separated  to  a  variable  extent,  depending  upon  the  retrac- 
tion of  the  muscle  to  which  it  belongs,  upon  the  position  in  which  the 
limb  is  placed,  and  upon  the  surrounding  attachments  of  the  tendon. 
Extending  beneath  the  ends  of  the  tendon  is  its  tubular  sheath  of  con- 
nective tissue,  and  it  is  this  which  chiefly  furnishes  the  reparative  mate- 
rial. 

The  sheath  becomes  vascular  and  succulent,  and  after  the  absorp- 
tion of  the  blood  that  has  been  effused  within  it,  the  interval  between 


Fig.  479. — Relapsed  Resistant  Congenital  Club-foot  in  a  Bo_v  of  Eight.     Rear  view! 


the  divided  ends  of  the  tendons  becomes  filled  with  lymph,  which  grad- 
ually becomes  fibrillated  and  forms  a  firm  bond  of  union  between  them. 

The  new  material  so  closely  resembles  the  old  tendon  and  is  so  in- 
timately blended  with  it  that  for  a  time  it  would  be  difficlilt  to  distin- 
guish them,  except  for  a  certain  translucency  which  is  possessed  by  the 
former,  and  is  not  natural  to  the  latter.  By  this  means  the  divided  ten- 
don is  increased  in  length  to  the  extent  of  the  interval  by  which  its 
ends  are  separated,  and  elongation  will  vary  according  to  the  amount  of 
separation. 

If  after  the  operation  treatment  is  carried  out  with  ordinary  care 
and  skill  on  a  healthy  subject,  a  useful  muscle  is  obtained. 


TALIPES. 


535 


Adhesions  may,  and  doubtless  often  do,  form  between  the  divided 
tendons  and  the  surrounding  structure,  but  in  ordinary  cases  they  are 
not  of  consequence,  for  they  give  way  in  the  use  of  the  foot,  and  do  not 
interfere  with  the  function  of  the  muscle. 

Much  undeserved  opprobrium  for  a  time  fell  upon  the  procedure  of 
tenotomy.  In  half-cured  and  relapsed  cases  atrophy  and  functional  dis- 
ability of  the  muscles  will  be  found ;  but  there  is  no  evidence  to  de- 
monstrate that  tenotomy,  when  properly  performed,  exerts  an  unfavor- 
able influence  upon  the  muscle. 

Division  of  the  Ligaments. — Division  of  the  ligaments  ^  is  of  use  in 
the  correction  of  club-foot. 

For  division  of  the  astragalo-scaphoid  ligament,  the  skin  and  soft 
tissues  should  be  punctured  down  to  the  bone  by  the  insertion  of  the 


Fig.  480. — Soles  of  Relapsed  Resistant  Congenital  Club-foot  in  a  Boy  of  Eight. 

tenotome.  It  should  then  be  inserted  in  front  of  the  internal  malleolus 
and  pushed  directly  to  the  underlying  bone,  and  swept  subcutaneously 
around  the  bone,  keeping  close  to  it.  The  knife  should  be  kept  between 
the  skin  and  ligaments,  and  the  latter  divided  by  a  sawing  motion  of  the 
tenotome.  This  division,  if  satisfactorily  and  thoroughly  made,  may 
serve  in  certain  cases  as  a  substitute  for  the  division  of  the  tibialis  ten- 
dons. 

The  calcaneo-cuboid  ligament  should  also  be  divided  in  severe  cases. 
The  tenotome  should  be  inserted  a  short  distance  behind  the  head  of 
the  fifth  metatarsal  bone,  near  the  articulation  of  the  os  calcis  and 
cuboid,  which  can  be  felt  on  palpation.  The  sharp-pointed  tenotome 
should  be  inserted  to  the  bone,  and  then  by  careful  motion  the  whole 
ligament  should  be  divided. 

'  London  Path.  Soc. ,  British  Med.  Jour.,  1886,  vol.  ii.,  p.  10. 


536  ORTHOPEDIC  SURGERY. 

Subcutaneous  tenotomy  of  all  the  parts  which  obstruct  the  complete 
restoration  is  performed.  This  in  most  cases  consists  of  division  under 
an  anaesthetic  of  the  plantar  fascia,  the  ligament  of  the  scapho-astraga- 
loid  joint,  and  last,  the  tendo  Achillis.  After  the  tenotomy  of  the  first 
three  the  foot  is  forcibly  corrected  by  the  hand,  and  a  division  of  the 
resisting  parts  carried  to  such  a  point  that  the  foot  can  be  easily  brought 
beyond  the  normal  plane,  after  which  tenotomy  of  the  tendo  Achillis  is 
done  and  the  foot  placed  in  plaster  in  an  overcorrected  position. 

In  case  the  restoration  has  not  been  perfect,  as  sometimes  happens 
with  more  resistant  feet,  it  is  well  to  remove  the  plaster  at  the  end  of 
ten  days  and  apply  the  brace  which  is  to  be  w^orn,  reapplying  the  ap- 
paratus every  two  or  three  days.  In  this  way,  before  complete  consol- 
idation has  taken  place,  a  certain  amount  of  gain  can  be  made  and  over- 
correction be  obtained  at  the  end  of  a  few  weeks,  which  at  first  was 
impossible.  If,  however,  the  restoration  has  been  complete  it  is  better 
to  keep  the  bandages  on  for  from  six  to  twelve  weeks,  in  order  that  the 
foot  may  not  be  disturbed  from  its  overcorrected  position.  When  the 
bandages  are  removed  great  care  should  be  taken  that  the  foot  is  not 
allowed  to  drop  from  its  overcorrected  position,  and  thus  make  traction 
on  the  ligaments  and  soft  parts  in  which  contraction  is  desired. 

When  the  plaster  bandages  are  removed  the  retention  appliance, 
described  above,  is  to  be  used  so  long  as  there  is  any  tendency  to  an 
incorrect  position. 

The  permanence  of  the  correction  depends  on  the  establishment  of 
an  accurate  balance  of  the  antagonism  of  muscles  and  other  soft  parts 
when  the  foot  is  in  normal  position.  The  after-treatment  by  retention 
must  be  persisted  in  until  the  child  is  able,  without  special  effort,  to 
walk  with  the  foot  in  a  natural  position;  otherwise  a  relapse  will  occur. 

The  sooner  the  foot  is  corrected  the  better,  provided  the  patient's 
general  condition  is  satisfactory,  and  that  treatment  is  not  liable  to  be 
interrupted  by  intercurrent  infantile  disorders;  practically,  treatment 
should  be  undertaken  as  soon  as  an  infant  is  nursing  well  and  is  in  rea- 
sonable health. 

The  use  of  retention  apparatus  will  be  necessary  for  some  years  and 
should  be  discontinued  gradually.  The  parent  may  aid  in  the  treatment 
by  daily  manipulating  the  feet  into  the  overcorrected  position.  The 
treatment  described  covers  in  general  all  that  is  necessary  for  infantile 
club-foot. 

The  length  of  time  during  which  the  appliance  is  needed  in  after- 
treatment  varies  and  is  in  general  in  inverse  proportion  to  the  size  of 
the  foot  or  the  difficulty  of  correction,  infants  in  arms  needing  a  reten- 
tion appliance  relatively  longer  than  is  necessary  in  adult  cases,  in 
which,  if  correct  gait  with  proper  weight-bearing  upon  the  sole  is  se- 
cured for  a  few  months,  relapses  are  not  to  be  expected. 


TALIPES.  537 

Summary  of  Mechanical  Treatment. — In  simple  cases  one  may 
attempt  correction  (i)  by  manual  manipulation  repeated  several  times 
daily,  (2)  by  plaster  bandages  applied  at  intervals  of  two  or  three 
weeks,  (3)  by  the  use  of  a  corrective  brace  constantly  worn,  (4)  by  the 
subcutaneous  division  of  tendons,  fasciae,  and  ligaments  followed  by 
immediate  overcorrection  in  a  plaster  bandage.  Without  after-treat- 
ment relapse  will  follow  in  practically  all  cases.  After-treatment  con- 
sists in  the  use  of  a  retention  brace  and  daily  manipulation  of  the  foot. 

Operative  Correction. 

In  cases  too  resistant  to  be  corrected  by  the  means  described  the 
following  radical  measures  may  be  employed : 

I  St.  Open  incision. 

2d.  The  use  of  extreme  force. 

3d.  Tarsal  osteotomy. 

Open  Incision. — The  chief  difficulty  is  in  obstinate  cases  to  stretch 
the  contracted  tissue  on  the  concave  side  of  the  distortion.  Phelps' 
open  incision  on  the  inner  and  plantar  surface  is  of  use  in  these  cases. 

The  advantage  of  open  incision  in  club-foot  is  the  facility  of  com- 
plete and  thorough  division  of  all  the  soft  tissues  to  the  bone.  The 
method  by  which  this  is  done  is  as  follows :  The  skin  is  divided  along 
the  inner  side  of  the  foot,  from  the  tip  of  the  malleolus  well  down  on 
the  inner  edge  of  the  first  metacarpal  bone.  After  the  skin  is  incised, 
the  other  tissues  are  cut  with  care,  using  a  director  if  necessary.  The 
insertion  of  the  tibialis  tendon  is  found  and  cut  across.  The  artery  can 
be  spared  by  careful  dissection,  but  if  necessary  it  can  be  divided  and 
tied.  The  plantar  fascia  on  the  sole  of  the  foot  should  be  divided  by 
the  use  of  a  tenotome,  or  long,  thin  knife.  A  cross  incision  toward  the 
sole  of  the  foot  from  the  middle  of  the  long  incision  is  sometimes  nec- 
essary, but  it  is  desirable  to  avoid  this  if  possible.  A  triangular  incision 
with  its  apex  upward  toward  the  ankle,  instead  of  the  cross-cut  of  the 
skin  and  fascia,  is  equally  efficient  and  diminishes  the  gap  after  correct- 
ing the  foot.^ 

Forcible  Manipulation. — Even  if  tenotomy  and  thorough  open 
incision  are  done,  a  certain  amount  of  resistance  remains  from  the  in- 
terosseous ligament  connecting  the  tarsal  bones.  Considerable  force 
is  often  necessary  to  bring  the  foot  into  an  overcorrected  position. 
This  can  be  done  either  by  manual  force  or  by  the  aid  of  mechanical 
force.  Several  wrenches  for  this  purpose  have  been  devised ;  that  of 
Thomas  is  the  simplest  and  is  sufficiently  efficient  when  no  bone  ob- 
struction exists.  The  foot  is  then  brought  into  as  normal  a  position  as 
possible,  thorough  aseptic  dressings  are  applied,  and  the  foot  is  then 

^  Jonas  :  Annals  of  Surgery,  April,  1897,  449. 


538 


ORTHOPEDIC  SURGERY. 


fixed  in  a  plaster-of-Paris  bandage  reaching  above  the  knee  and  holding 
the  well-padded  and  aseptically  dressed  foot  in  an  overcorrected  posi- 
tion. If  the  dressing  is  provided  with  efficient  protectors  and  sufficient 
dressings,  no  change  in  the  bandage  need  be  made  for  a  fortnight  or 
longer.  If  necessary,  however,  a  window  can  be  cut  in  the  plaster  over 
the  wound  and  the  dressings  changed.  After  the  plaster  of  Paris  is 
discarded  the  retention  shoe  is  to  be  w^orn. 

The  use  of  manual  force  without  any  previous  cutting  operation  will 
rectify  the  deformity  in  club-foot,  and  such  a  method  is  in  use.  The 
inward  twist  of  the  foot,  at  the  mediotarsal  joint,  is  first  corrected  by 


Fig.  481. -Thomas  Club-foot  Wrench,  Modified.     (Hoflfa.) 

grasping  the  heel  in  one  hand  and  the  forefoot  in  the  other  and  stretch- 
ing the  inner  side  of  the  foot,  either  by  the  hands  alone  or  by  bending 
it  over  the  padded  edge  of  a  triangular  block  of  wood. 

The  inversion  of  the  sole  of  the  foot  is  then  corrected  by  a  similar 
series  of  manipulations,  until  the  sole  of  the  foot  is  everted  and  will  stay 
in  that  position  without  the  use  of  force. 

The  plantar  fascia  is  next  stretched  and  the  height  of  the  arch  re- 
duced by  flexing  the  foot  dorsally  against  the  force  of  the  tendo  Achillis. 

The  reduction  of  the  astragalus  to  its  proper  position  between  the 
malleoli  is  next  undertaken.  The  tendo  Achillis  is  divided  by  a  teno- 
tome, and,  if  necessary,  the  posterior  ligament  of  the  ankle-joint. 


TALIPES. 


539 


The  child  is  now  turned  on  the  face,  and  the  front  of  the  thigh  hes 
on  the  table  with  the  knee  flexed  and  the  leg  vertical.  The  operator 
hooks  his  fingers  around  the  os  calcis  while  the  hand  lies  on  the  sole  of 
the  foot  to  force  it  into  dorsal  flexion.     This  is  done  by  a  series  of  forci- 


FlG.  482.  — Manipulative  CorrecLiou  of  Club-foot.     (After  Lorenz.) 

ble  pressings  downward  on  the  sole  of  the  foot,  until  the  dorsum  of  the 
foot  nearly  touches  the  tibia.  The  foot  is  now  limp  and  can  be  held  in 
an  overcorrected  position  without  the  use  of  force.  In  this  position  a 
plaster  bandage  is  applied. 

The  disadvantages  of  the  operation  lie  in  the  unnecessary  violence 
used  to  obtain  a  result  which  can  more  easily  be  reached  by  cutting  re- 
sisting structures.  The  use  of  manipulative  force  is  a  well-recognized 
and  useful  preliminary  to  all  forms  of  operation  for  club-foot.  The 
experience  of  the  writers  has  led  them  to  prefer  the  removal  of  a  wedge 


A  Q 

Fig.  4S3. — Lever  Correction  Apparatus  TApplied), 

of  bone  to  the  use  of  extreme  force  in  cases  which  are  still  resistant 
after  the  use  of  the  measures  just  described.^ 

In  applying  the  bandages,  it  is  of  course  important  that  the  foot 
should  be  held  in  an  overcorrected  position  until  the  plaster  becomes 
hard,  as  no  further  correction  can  take  place  under  the  bandage.  In 
the  majority  of  cases  perfect  correction  or  overcorrection  is  possible, 

'  Phillipson  :  Deut.  Zeitschr.  f.  Chir.,  xxviii. 


540 


ORTHOPEDIC  SURGERY. 


and  the  foot  can  be  held  in  proper  position  for  the  apphcation  of  the 
fixation  bandage  without  much  force. 

Osteotomy. — When  but  a  slight  amount  of  osseous  distortion  is 
present  forcible  correction  aided  by  tenotomy  or  open  incision  will  be 
sufficient  to  overcome  the  deformity,  but  in  the  more  resistant  cases. 


Fig.  484.— Double  Congenital  Club-foot  Before  Operation. 


changes  in  the  shape  of  the  tarsal  bones  forming  the  mediotarsal  joint 
prevent  perfect  cure,  and  operation  upon  the  bones  is  necessary. 

Astragaloid  Osteotomy. — hx\  examination  of  the  anatomy  of  resist- 
ant club-foot  shows  that  the  facet  of  the  astragalus  in  the  astragalo- 
scaphoid  articulation  is  on  the  side  instead  of  in  front.  There  is  also 
some  obliquity  of  the  neck  of  the  astragalus.  If  this  obstruction  of  the 
bone  can  be  corrected  and  the  front  of  the  foot  brought  into  place,  there 
would  be  less  tendency  to  relapse. 

It  is  essential,  in  every  inveterate  case  of  club-foot,  that  if  the  foot 
is  to  be  unfolded,  the  shortened  tissues  in  the  arch  of  the  foot  and  in 
the  inner  side  of  the  foot  be  stretched,  torn,  or  divided.  This  can  be 
done  safely  by  means  of  tenotomy,  forcible  stretching,  or  open  incision ; 


TALIPES. 


541 


but  the  deformity  of  the  astragalus  still  remains.  In  many  cases,  even 
if  somewhat  resistant,  if  the  deformity  is  rectified  and  the  foot  held  a 
sufficient  time  in  the  proper  position,  and  a  proper  walking  shoe  used 
for  a  year,  a  new  facet  of  the  astragalus  will  be  formed  and  a  cure 
effected.  In  a  few  cases  this  is  not  the  case,  and  in  such  instances  os- 
teotomy of  the  neck  of  the  astragalus  suggests  itself  as  a  suitable  oper- 
ation. 

The  procedure  will  not  be  found  a  difficult  one.     Tenotomy  or  open 
incision  and  division  of  the  fascia  and  ligaments  should  be  done,  and 


Fig.  485.— Same  Case  Six  Weeks  After  Operation  by  Forcible  Correction. 

the  foot  stretched  and  manipulated  into  as  nearly  normal  a  position  as 
possible.  An  incision  through  the  skin  is  made  from  the  tip  of  the 
malleolus  to  the  inner  side  of  the  head  of  the  first  metatarsal,  which 
will  be  found  in  severe  cases  close  to  the  malleolus.  The  incision  is 
close  to  and  nearly  parallel  to  the  tibialis  anticus  tendon,  and  in  the 
direction  of  the  metatarsal.  The  incision  should  be  made  to  the  bone 
and  the  foot  straightened,  as  the  metacarpal  bone  is  separated  from  the 
malleolus.  The  scaphoid  will  be  seen  before  the  astragalus  is  encoun- 
tered, if  the  deformity  is  great,  and  it  will  be  first  within  the  reach  of 
the  knife  in  all  cases.  If  the  foot  is  still  further  stretched,  the  scaphoid 
begins  to  uncover  the  side  of  the  astragalus,  and  the  neck  of  the  astrag- 
alus is  seen ;  a  small  osteotome  is  entered  and  placed  upon  the  neck  of 
the  astragalus,  to  the  proximal  side  of  the  scaphoid  articulation,  and  the 


542 


ORTHOPEDIC  SURGERY 


neck  of  the  astragalus  divided  or  nearly  divided.  The  foot  is  then  for- 
cibly straightened,  and  the  neck  of  the  astragalus  unchiselled  is  fract- 
ured. The  result  is  similar  to  that  in  Macewen's  operation  for  knock- 
knee,  and  the  distortion  at  the  neck  of  the  astragalus  is  removed.  It  is 
manifest  that  the  line  of  section  of  the  bone  at  the  neck  of  the  astraga- 
lus should  be  transverse  to  the  axis  of  the  bone,  and  at  such  a  plane 
that  when  the  equinus  deformity  is  corrected  the  resulting  gap  at  the 
section  should  not  be  greater  than  necessary.  The  foot  should  be  fixed 
in  an  overcorrected  position.  A  wedge-shaped  resection  of  the  neck  of 
the  astragalus  through  a  skin  incision  in  the  outer  and  upper  surface  of 
the  foot  has  been  performed,  but  linear  osteotomy 
would  seem  to  be  preferable. 

Osteotomy  of  t/ic  Head  of  tJie  Os  Ceilcis. — The 
relation  of  the  cuboid  to  the  os  calcis  is  frequently 
masked,  lying  deeper  than  that  of  the  scaphoid  and 
astragalus,  and  it  may  in  treatment  be  but  par- 
tially corrected.  The  distortion  of  the  os  calcis  at 
its  anterior  aspect,  if  not  corrected,  increases  and 
forms  an  obstacle  to  the  complete  restoration  of 
the  cuboid  to  the  normal  position,  although  the 
rest  of  the  deformity  may  have  been  corrected. 

When  the  cuboid  is  cartilaginous  and  the  liga- 
ments are  well  stretched,  the  defect  at  the  anterior 
portion  of  the  os  calcis  can  be  overcome  by  forc- 
ibly correcting  the  foot  and  retaining  it  in  the 
corrected  position  by  means  of  a  plaster-of-Paris 
bandage,  care  being  taken,  however,  that  the  cuboid 
be  restored  to  place,  and  in  time  it  will  be  found 
that  the  cartilaginous  abnormality  in  the  shape  of  the  os  calcis  is  grad- 
ually changed  under  corrected  pressure. 

When  distortion  of  the  head  of  the  os  calcis  is  great,  no  amount  of 
mechanical  treatment  can  overcome  the  obstacle,  if  it  is  of  bone  and  if 
the  ligaments  are  strong,  binding  the  bones  in  a  distorted  position.  It 
is  manifest  under  these  circumstances  that  the  rational  treatment  is  a 
removal,  not  of  the  astragalus  or  cuboid,  but  of  a  part  of  the  projecting 
portion  of  the  head  of  the  os  calcis. 

After  complete  stretching  or  division  by  tenotomy,  force,  or  open 
incision  of  the  contracted  tissues  on  the  inner  and  under  side  of  the 
foot,  tendons,  ligaments,  and  fasciae,  if  it  is  found  that  the  front  of  the 
foot  cannot  be  brought  to  a  perfectly  corrected  or  overcorrected  posi- 
tion, an  incision  should  be  made  on  the  outer  side  of  the  foot,  passing 
from  behind  the  external  malleolus  forward  and  downward.  The  incis- 
ion should  be  a  curved  one,  and  the  chief  convexity  should  be  at  the 
forward  portion  of  the  os  calcis.     This  incision  should  reach  to  the 


Fig.  486.— From  Photo- 
graph after  Removal 
of  Astragalus  of  Left 
Foot  for  Club-foot. 


TALIPES. 


543 


Fig.  487.— Sole  Imprint  after  Removal  of  FiG.    488.— Sole  Imprint  of  Case  of  Club-foot 

Astragalus  for  Club-foot.  Corrected  by  Tenotomy,  without  Contrac- 

tion but  with  Inversion  of  the  Foot. 

bone  and  should  expose  the  peroneal  tendons.  These  can  either  be 
drawn  to  the  side  or  divided  to  be  stitched  later.  The  upper  portion  of 
the  incision  should  reach  behind  the  external  malleolus,  and  should  ex- 


FiG.  489.— Imprint  of  Left  Foot  before  Opera-        Fig.  490.— Imprint  of  Left  Foot  after  Opera- 
tion, tion. 


544 


ORTHOPEDIC  SURGERY. 


tend  far  enough  up  to  allow  sufficient  retraction  of  the  flap  to  give  room 
for  the  osteotomy.  After  the  bone  has  been  reached,  and  the  periosteum 
divided  and  pushed  aside,  an  osteotome  should  be  inserted  far  enough 
back  to  remove  a  sufficient  amount  of  bone.  The  direction  of  the  inser- 
tion of  the  osteotome  should  be  such  as  to  allow  the  placing  of  the  cu- 
boid, after  the  bone  has  been  removed,  in  a  normal  position.  This  step 
of  the  operation  requires  some  nicety  and  judgment,  as  it  is  of  impor- 
tance that  the  front  plane  of  the  bone,  after  the  wedge  has  been  re- 


^ 

n 

i!iJp 

JHRh 

K^ 

J 

y^ 

Fig.  491.— Case  of  Bad  Relapsed  Congenital  Club-foot  in  a  Woman  of  Thirty-four,  Corrected 
by  Force  with  the  Use  of  a  Wrench.     Photograph  taken  three  months  after  correction. 


moved,  should  be  in  the  direction  of  the  normal  facet  of  the  front  of  the 
OS  calcis.  A  ^vedge-shaped  portion  of  bone  should  be  removed  from  the 
anterior  and  outer  part  of  the  os  calcis,  and  the  cartilaginous  ends  saved 
in  order  to  allow  a  proper  amount  of  motion  between  the  cuboid  and 
the  OS  calcis  after  recovery.  The  wedge-shaped  portion  of  bone  that 
should  be  removed  should  be  ample  and- enough  to  allow  the  replace- 
ment of  the  front  of  the  foot  in  a  normal  or  overcorrected  position 
and  the  restoration  of  the  proper  direction  of  the  os  calcis. 

The  wound  should  be  carefully  washed  out  to  remove  any  frag- 
ments of  bone  that  may  have  been  left,  and  subsequently  stitched ;  the 
tendon  of  the  peroneus  longus,  if  divided,  being  stitched.  The  foot 
should  then  be  dressed  with  proper  dressings  and  fixed  in  an  overcor- 


TALIPES. 


545 


rected  position  by  plaster  bandages  according  to  the  ordinary  rules  in 
osteotomy. 

Whether  this  operation  should  be  done  in  connection  with  an  oste- 
otomy of  the  neck  of  the  astragalus,  and  with  an  open  incision  at  the 
same  sitting,  is  a  matter  of  judgment  in  each  case. 

Imperfect  results  are  due  to  neglect  of  thorough  asepsis,  failure  to 
remove  a  sufficient  amount  of  bone,  failure  to  remove  it  in  such  a  direc- 
tion as  to  cure  the  deformity,  and  lack  of  care  in  placing  the  foot  in  an 
overcorrected  position  after  operation. 

While  the  plaster  is  hardening  the  cuboid  is  pressed  upward  and 
outward,  and  the  front  of  the  foot  pressed  outward  and  upward,  counter- 


PiG.  492.— Case  of  Bad  Relapsed  Congenital  Club-foot  in  a  Woman  of  Thirty-four,  Corrected 
by  Force  with  the  use  of  a  Wrench.  Photograph  taken  three  months  after  correction; 
showing  cicatrix  of  the  tear  of  the  skin  caused  by  correction.     (See  Fig.  491.) 


pressure  being  applied  on  the  astragalus  on  the  outer  and  upper  side, 
and  the  os  calcis  twisted  into  its  normal  position. 

Treatment  can  be  carried  out  with  a  plaster-of- Paris  bandage  until 
the  foot  is  thoroughly  healed,  and  also  until  locomotion  has  been  re- 
established. After  this  the  use  of  the  club-foot  shoe  is  advisable  for 
at  least  some  months. 

Relapses. — No  error  is  greater  than  a  common  one,  namely,  that 
tenotomy  alone  is  sufficient  to  correct  club-foot.  In  fact,  tenotomy  is 
only  the  beginning  of  a  course  of  treatment.  If  the  foot  is  rectified 
and  held  in  place  for  a  month,  it  is  supposed  by  some  surgeons  that  a 
cure  has  been  effected.  But  such  is  by  no  means  the  case. 
35 


546  ORTHOPEDIC  SURGERY. 

Moreover,  it  must  always  be  borne  in  mind  that  relapses  will  inva- 
riably occur  unless  the  distortion  is  overcorrected,  and  little  reliance 
can  be  placed  on  the  curative  effect  of  time.  Efforts  at  correction 
should  be  continued  until  the  foot  can  be  easily  abducted  beyond  the 
median  line,  and  while  slightly  abducted,  can  be  flexed  so  that  the  dor- 
sum of  the  foot  shall  form  less  than  a  right  angle  with  the  leg,  the 
sole  of  the  foot  being  flat,  and  there  being  no  twist  in  the  front  of  the 
foot.  After  this  the  correction  appliance  can  be  gradually  omitted 
while  manipulation  of  the  foot  is  still  carried  on,  and  the  case  should 
be  kept  under  observation. 

Relapses  occur  in  a  certain  number  of  cases  simply  from  the  care- 
lessness of  the  parents,  who  are  not  aware  of  the  necessity  of  retaining 
the  corrected  foot  in  the  proper  position  for  a  long  time.  In  such 
cases  a  second  operation  is  advisable. 

Relapses  in  older  children  are  clue  to  incomplete  correction,  either 
from  a  lack  of  thoroughness  or  from  the  existence  of  an  unusual  amount 
of  distortion  of  the  astragalus  or  os  calcis  not  suspected,  and  demand- 
ing osteotomy,  or  from  too  early  removal  of  the  fixation  or  retention 
appliance.      ■ 

In  some  instances  of  resistant  club-foot  it  is  found  difficult,  in  cor- 
recting the  foot,  completely  to  overcorrect  the  equinus  deformity,  and 
to  enable  the  foot  to  be  brought  to  within  a  right  angle  with  the  leg. 
If  this  is  not  done,  inconvenience  is  felt  by  the  patient  in  taking  a  long 
step,  and  the  foot  is  turned  in  to  facilitate  this.  The  smaller  the  foot 
the  greater  this  danger.  If  this  is  not  corrected,  it  may,  in  some  in- 
stances, seriously  interfere  with  the  excellence  of  the  result. 

It  should  always  be  borne  in  mind  that  a  distortion  in  the  neck  of 
the  astragalus  or  in  the  head  of  the  os  calcis  exists,  even  in  infantile 
club-foot,  and  that  the  feet  are  not  permanently  corrected  until  the 
alteration  of  the  facets  into  a  normal  position  has  taken  place.  This  is 
independent  of  bringing  the  foot  into  a  normal  position,  and  demands 
fixation  in  an  overcorrected  position  for  some  time.  In  some  cases  this 
is  more  needed  than  in  others,  probably  because  the  alterations  of  the 
facets  of  the  astragalus  are  in  some  instances  slight. 

Too  great  overcorrection  of  the  deformity  and  the  development  of  a 
splay-foot  have  sometimes  resulted  from  overzealous  treatment.  The 
danger  is,  however,  not  great ;  and  instances  are  rare,  and  are  to  be 
overcome  by  the  treatment  for  a  valgus  foot. 

Inversion  of  the  foot,  after  cure  of  the  club-foot,  may  in  a  few  in- 
stances be  observed  from  imperfect  strength  of  the  outward  rotatory 
muscles  at  the  hip.  This,  however,  causes  but  little  disfigurement,  the 
inversion  usually  being  slight,  and  correcting  itself  by  the  normal  devel- 
opment of  the  muscles.  A  marked  toeing-in  of  the  foot  in  running  per- 
sists a  long  time  in  some  instances  in  which  the  foot  is  entirely  cor- 


TALIPES.  S47 

rectecl  and  the  walking  is  normal.  It  disappears  wiih  the  increase  of 
muscular  strength.  In  such  cases  the  ordinary  Taylor  shoe  should  be 
carried  up  to  the  hip  by  means  of  an  upright  on  the  outside  of  the  leg 
and  a  posterior  arm  carried  back  from  the  level  of  the  trochanter,  as  in 
the  knock-knee  splint.     By  tightening  this,  eversion  is  secured. 

A  relaxed  state  of  the  knee-joint  causing  inversion  of  the  tibia  is  not 
uncommon  in  infantile  club-foot ;  it  usually  corrects  itself  in  the  devel- 
opment of  the  child  after  correction  of  the  foot.  In  rare  instances, 
however,  it  may  persist,  requiring  the  longer  use  of  a  walking  appliance. 

The  muscles  retarded  in  club-feet  by  disuse  need  development  be- 
fore a  complete  cure  is  effected.  Ordinarily  the  muscles  develop  of 
themselves  after  complete  correction,  if  the  limbs  are  actively  used.  In 
some  cases  the  development  is  slow  and  massage  and  electricity  are 
advisable. 

Generalization  as  to  Treatment. — The  literature  of  the  treat- 
ment of  club-foot  is  too  often  that  of  unvarying  success.  It  is  some- 
times as  brilliant  as  an  advertising  sheet,  and  yet  in  practice  there  is  no 
lack  of  half -cured  or  relapsed  cases — sufficient  evidence  that  methods  of 
cure  are  not  universally  understood. 

Surgeons  differ  somewhat  in  regard  to  the  method  of  treatment  of 
club-foot,  but  the  following  statements  are  regarded  by  the  writers  as 
worthy  of  acceptance : 

FirsL — It  is  possible  to  correct  completely  infantile  cases  of  con- 
genital club-feet  without  the  help  of  any  operative  interference,  even 
tenotomy. 

Second. — Tenotomy,  however,  even  in  infants  is  of  assistance,  and  in 
older  cases  is  in  almost  all  instances  necessary  for  a  perfect  cure.  Te- 
notomy properly  done  is  not  followed  by  any  unfavorable  results  to  the 
muscles. 

77^zr^.— Certain  resistant  cases  can  be  corrected  and  cured  without 
operation  upon  the  bone,  but  in  such  cases  considerable  force  must  be 
used. 

Fourth. — In  resistant  cases,  however,  when  there  is  deformity  of  the 
bone,  osteotomy  or  a  wedge-shaped  resection  of  the  astragalus  or  os 
calcis  is  necessary. 

Fifth. — Congenital  club-foot  is  a  thoroughly  curable  deformity,  pro- 
vided the  pathological  conditions  existing  are  thoroughly  understood, 
and  the  resisting  structures  overcome. 

Sixth. — For  cure,  overcorrection  of  the  deformity  is  necessary  and 
retention  in  an  overcorrected  position  until  the  normal  relation  of  the 
parts  has  been  established. 

Seventh. — The  best  retention  appliance  is  one  which  mterferes  with 
the  normal  motion  the  least  without  permitting  the  distorted  position 
of  the  foot. 


548  ORTHOPEDIC  SURGERY. 

Acquired  Club-Foot — Paralytic  Deformity. 

The  most  common  form  of  acquired  talipes  equmo-varus  is  that  fol- 
lowing infantile  paralysis  which  is  described  in  another  chapter. 

The  prognosis  of  paralytic  club-foot  is  necessarily  more  unfavorable 
than  that  of  the  congenital  form,  although  the  distortion  is  more  readily - 
corrected ;  it  is  impossible  to  restore  the  affected  muscles  to  a  normal 
condition,  and  the  prolonged  use  of  some  form  of  appliance  may  be 
necessary.  In  some  instances,  however,  after  thorough  correction  and 
retention  for  a  while  in  a  corrected  position,  if  the  foot  is  of  sufficient 
size,  relapse  does  not  take  place,  or  does  so  only  in  a  partial  degree,  and 
a  useful  and  but  slightly  distorted  foot  remains. 

The  correction  of  paralytic  club-foot  is  to  be  conducted  on  the  same 
principles  as  that  of  the  congenital  type.  Correction  is,  however,  much 
less  difficult,  as  osseous  changes  are  present  only  in  the  old  severe  and 
neglected  cases. 

Tenotomy  of  the  contracted  and  healthy  muscles  can  be  done  as  in 
congenital  cases,  though  overcorrection  after  tenotomy  is  to  be  avoided. 
Immediate  correction  and  fixation  in  a  corrected  position  are  to  be  used 
after  tenotomy  as  in  the  congenital  form. 

Tendon  transferrence  and  arthrodesis  as  applied  to  this  affection  are 
discussed  under  infantile  paralysis. 

The  walking  appliance  to  be  used  in  paralytic  cases  is  in  general  the 
same  as  that  which  has  been  described  in  congenital  cases. 

TALIPES    EQUINUS. 

(Pes  equinus,  Horse  heel.  Pied  bot  equin,  Pferdefuss,  and  Spitzfuss.) 

Talipes  equinus  is  the  name  given  to  a  condition  in  which  the  foot  is 
held  in  a  position  of  plantar  flexion  and  cannot  be  dorsally  flexed  to  the 
normal  extent  (twenty  degrees  beyond  a  right  angle). 

Varieties. — Talipes  equinus  may  be  congenital  or  acquired.  Con- 
genital equinus  is  an  uncommon  deformity,  constituting  about  five  per 
cent  of  all  cases  of  equinus.  In  i,66o  congenital  deformities  of  the 
foot  there  were  40  cases  of  equinus.  Its  origin  is  no  more  clear  than 
that  of  other  similar  congenital  deformities.  The  congenital  form  of 
the  deformity  is  generally  not  severe. 

Acquired  Talipes  Equinus. 

In  the  acquired  forms  all  degrees  of  deformity  are  met,  from  the 
slight  condition  in  which  the  foot  cannot  be  flexed  dorsally  beyond  a 
right  angle  with  the  leg,  to  one  in  which  the  foot  and  leg  form  practi- 
cally a  straight  line. 


TALIPES. 


549 


Etiology. — The  causes  of  acquired  talipes  equinus  are  as  follows: 

1.  Infantile  paralysis  of  the  anterior  muscles  of  the  leg. 

2.  Cerebral  (spastic)  paralysis,  hemiplegia,  pseudo-hypertrophic 
paralysis,  neuritis,  and  similar  affections  causing  either  loss  of  power  in 
the  anterior  muscles  of  the  leg  or  an  overbalancing  of  these  muscles  by 
the  contraction  of  the  posterior  group. 

3.  Shortening  of  the  leg  after  joint  disease  or  fracture  may  lead  to 


Fig.  493. — Talipes  Equinus  of  Marked 
Degree.  This  represents  the 
■weight-bearing  position. 


Fig.  494. ^Talipes   Equinus   of  Left  Foot  Resulting 
from  Paralysis. 


an  adaptive  talipes  equinus  which   serves  to  make  the  legs  of  equal 
length  for  walking. 

4.  Talipes  equinus  may  be  a  symptom  or  result  of  disease  of  the 
ankle-joint. 

5.  Long  confinement  to  bed  may  cause  talipes  equinus,  which  is 
merely  the  result  of  the  long-continued  plantar  flexion  of  the  foot. 

6.  Fractures  may  result  in  talipes  equinus  either  from  injury  to  the 
ankle-joint  or  from  fixation  during  repair  in  a  plantar-flexed  position. 


550  ORTHOPEDIC  SURGERY. 

7.  Hysteria  may  be  a  cause. 

8.  The  contraction  caused  by  posterior  cicatrices  or  the  loss  of  power 
due  to  division  or  injury  of  the  anterior  muscles  and  tendons  of  the  leg 
may  cause  the  deformity. 

Pathology. — The  structural  changes  in  talipes  equinus  are  slight. 
In  a  large  number  there  is  simply  a  shortening  in  the  Achilles  tendon 
or  muscles,  with  a  consequent  alteration  in  the  shape  or  relation  of  the 
bones  and  soft  tissues  of  the  foot.  Some  cases,  however,  are  due  less 
to  the  raising  of  the  calcaneum  than  to  a  depression  of  the  head  of  the 
astragalus,  which  may  be  depressed  nearly  in  a  vertical  line,  and  the 
arch  of  the  foot  increased  by  a  strong  flexion  at  the  medio-tarsal  joint. 

Symptoms. — The  deformity  in  its  slighter  degrees  is  not  particularly 
disabling.  In  its  severer  grades  it  is  the  cause  of  a  severe  limp  and  at 
times  of  much  discomfort.  A  slight  degree  of  the  affection  may  be 
enough  to  cause  a  limp  in  walking,  as  in  carrying  the  leg  back  at  the 
end  of  the  step  the  foot  should  be  bent  to  more  than  a  right  angle. 
Corns  and  calluses  of  a  severe  grade  are  frequently  found  on  the  sole 
at  the  front  of  the  foot.  They  may  be  a  source  of  severe  discomfort. 
In  cases  of  moderate  severity  the  weight  of  the  body  is  borne  on  the 
distal  end  of  the  metatarsals  in  walking,  the  toes  being  hyperextended. 
In  the  severest  forms  of  all  the  foot  is  bent  on  itself,  so  that  the  sole  is 
directed  backward  and  locomotion  takes  place  on  the  dorsal  surface  of 
the  metatarsus  and  toes.  The  arch  of  the  foot  is  generally  higher  than 
the  normal,  and  the  condition  which  will  be  described  as  pes  cavus  may 
coexist  with  the  equinus. 

In  the  severer  forms  there  is  a  marked  projection  on  the  dorsum  of 
the  foot  formed  at  the  site  of  the  calcaneo-cuboid  and  astragalo-scaph- 
oid  articulations.  As  locomotion  occurs  only  on  the  ball  of  the  foot, 
this  part  becomes  abnormally  wide,  and  in  time  the  plantar  fascia  con- 
tracts and  resists  the  reduction  of  the  malposition. 

The  spastic  form  is  most  commonly  met  in  spastic  paralysis  or  after 
hemiplegia.  As  this  is  due  to  the  contraction  of  the  muscles  of  the 
tendo  Achillis,  the  position  of  the  foot  in  this  differs  from  that  follow- 
ing paralysis.  The  heel,  in  the  spasmodic  form,  is  drawn  upward  and 
the  whole  foot  depressed  in  consequence.  There  is,  therefore,  less  ten- 
dency to  the  formation  of  an  angle  in  the  medio-tarsal  or  tarso-metatar- 
sal  joints. 

The  form  often  met  in  shortened  limbs,  as  after  recovering  from  hip 
disease,  fracture,  etc.,  is  the  result  of  the  maintenance  of  the  foot  for  a 
long  time  in  a  partially  extended  position,  in  the  act  of  walking  and 
standing.  In  these  cases  it  is  a  compensatory  arrangement,  inasmuch 
as  it  tends  to  keep  the  pelvis  level,  and  not  to  be  regarded  as  objection- 
able except  in  its  appearance. 

The  detection  of  talipes  equinus  is  a  simple  matter.     The  normal 


TALIPES.  5  5  I 

foot  should  be  capable  of  flexion  about  twenty  degrees  beyond  a  right 
angle,  and  any  cause  which  restricts  this  flexion  is  a  degree  of  talipes 
equinus. 

Treatment. — The  division  of  the  tendo  Achillis  will  relieve  the  de- 
formity in  all  cases  except  those  in  which  bony  deformity  exists  at  the 
ankle,  as  in  the  cases  following  fracture  and  tuberculosis  of  the  ankle- 
joint.  In  such  cases  or  in  extremely  severe  instances  of  deformity 
from  other  causes,  a  wedge-shaped  osteotomy  of  the  tarsus  might  be 
required  for  rectification,  but  this  would  be  unusual. 

The  deformity  should  be  at  once  corrected  after  tenotomy  and  a 
plaster-of-Paris  bandage  applied.  If  a  retention  appliance  is  required 
after  operation,  a  modification  of  the  club-foot  shoe,  with  the  ankle-joint 
arranged  to  stop  extension  at  a  right  angle,  will  be  found  to  be  effect- 
ual and  simple.  Or  a  simple  foot-piece  joined  to  two  uprights  and  a 
posterior  band  may  be  used,  which  is  jointed  in  the  same  way  at  the 
ankle.  This  prevents  the  foot  from  rolling  in  or  out  and  thus  makes 
the  act  of  walking  a  force  to  pull  upon  the  tendo  Achillis  at  each  step 
(Chapter  XXI.,  28). 

Acquired  talipes  equinus  is  in  most  cases  due  to  anterior  poliomye- 
litis, and  the  treatment  of  that  form  has  been  discussed  there.  In 
cases  due  to  ankylosis  of  the  ankle-joint  or  to  severe  acquired  distortion 
of  the  bone  from  prolonged  neglect,  a  wedge-shaped  osteotomy  might 
be  necessary. 

TALIPES  CALCANEUS. 

(Pes  calcaneus.  Pied  bot  calcaneen,  and  Hackenfuss.) 

Talipes  calcaneus  is  the  name  applied  to  a  condition  in  which  the 
foot  is  held  in  a  position  of  dorsal  flexion. 

Varieties. — The  deformity  may  be  congenital  or  acquired. 

It  is  a  comparatively  rare  congenital  deformity,  about  two-thirds  as 
common  as  congenital  equinus  (28  cases  in  1,660  cases  of  congenital 
deformity  of  the  foot).  The  hollow  in  the  sole  of  the  foot  so  often 
present  in  the  acquired  variety  is  likely  to  be  absent  in  the  congenital. 
It  may  be  noticed  only  as  a  slight  downward  prominence  of  the  heel  or 
it  may  be  so  severe  that  the  dorsum  of  the  foot  may  be  laid  against  the 
anterior  surface  of  the  tibia.  Its  etiology  is  practically  the  same  as 
that  of  the  other  congenital  deformities. 

Acquired  talipes  calcaneus  is  less  common  than  acquired  equinus. 
It  presents  the  same  characteristics  as  the  congenital  form,  except  that 
an  increased  hollowness  in  the  arch  of  the  foot  is  likely  to  coexist,  in 
which  case  the  deformity  may  be  spoken  of  as  talipes  calcaneo-cavus. 
The  cause  of  the  acquired  deformity  is  in  most  cases  paralysis  of  the 
muscles  of  the  calf  of  the  leg  from  anterior  poliomyelitis.  It  may  occur 
in  chronic  disease  of  the  ankle  as  a  symptom  of  muscular  irritability. 


552 


ORTHOPEDIC  SURGERY 


It  exists  sometimes  in  hysteria,  and  it  may  result  from  rupture  or  divis- 
ion of  the  posterior  muscles  of  the  leg,  from  cicatrices  in  the  front  of 
the   ankle,  and  from  ankylosis  of  the  ankle-joint  in  a  faulty  position. 

The  pathology  of  the  affection  is  manifested  by  the  changes  incident 
to  the  maintenance  and  use  of  the  foot  in  this  abnormal  position. 
Stretching  of  ligaments  and  muscles  are  found  on  one  side,  with  short- 
ening on  the  other  and  changed  relations  between  the  bones,  resulting 
perhaps  in  the  development  of  new  articular  facets. 

Symptoms.— The  patient  walks  upon  the  heel  and  the  gait  is  inelas- 
tic, because  the  spring  of  the  foot  is  absent  and  the  patient  walks  bear- 


FlG.  495. — Talipes  Calcaneus. 

ing  the  whole  weight  on  the  os  calcis.  The  diagnosis  presents  no  diffi- 
culty, except  that  it  must  be  remembered  that  the  association  of  the 
deformity  with  both  \'algus  and  cavus  is  frequent. 

Treatment. — In  congenital  cases  the  foot  should  be  daily  manipu- 
lated by  the  parents  into  a  position  of  plantar  flexion.  As  soon  as  the 
anterior  muscles  are  stretched,  it  is  advisable  to  put  the  foot  up  in  a 
position  of  plantar  flexion,  to  bring  about  adaptive  shortening  of  the 
posterior  muscles.  In  the  severer  cases  the  application  of  a  series  of 
corrective  plaster  bandages  holding  the  foot  in  plantar  flexion  may  be 
necessary.  Tenotomy  of  the  anterior  tendons  is  rarely  required. 
When  the  foot  can  be  plantar-flexed  to  the  normal  amount,  a  retention 
shoe  preventing  dorsal  flexion  may  be  applied,  but  in  slight  cases  this 
is  not  necessary  (Chapter  XXL,  29). 


TALIPES   VALGUS. 


Talipes  valgus  is  the  name  given  to  a  condition  which  is  not  in  all 
cases  to  be  clearly  differentiated  from  what  has  been  described  as  flat- 


TALIPES. 


553 


foot.  Talipes  valgus  may  be  congenital  or  acquired.  As  a  congenital 
deformity  it  is  one  of  the  more  common  of  the  congenital  deformities  of 
the  foot.  In  i,66o  cases  of  congenital  deformity  of  the  foot  there  were 
123  of  congenital  valgus.  The  bones  in  congenital  flat-foot  even  in 
severe  cases  show  but  little  alteration  in  shape.  The  astragalus  is 
turned  obliquely  to  one  side  and  downward,  and  the  angle  of  the  artic- 
ulation faces  more  to  the  side  than 
is  normal.  The  end  of  the  os  calcis 
may  be  slightly  raised.  The  sca- 
phoid is  turned  to  the  outer  side 
and  is  rotated  on  its  central  axis,  so 
that  the  outer  side  is  slightly  raised 
and  the  inner  side  is  lowered — the 


Fig.  496. — Moderate    Degree   of  Talipes 
Valgus,  Right  Foot. 


Fig.  497.— Talipes  Varus,  Right  Foot. 


arch  of  the  foot  is  obliterated  and  the  inner  border  is  often  convex 
rather  than  concave. 

It  may  exist  by  itself  or  in  connection  with  other  defects  of  the 
bones  of  the  foot  or  leg.  It  may  exist  alone  or  associated  with  calca- 
neus or  equinus.  The  deformity  of  congenital  valgus  is  likely  to  be 
extreme  and  the  sole  of  the  foot  may  present  a  downward  convexity. 
The  three  elements  mentioned  in  flat-foot — abduction  of  the  front 
of  the  foot,  eversion  of  the  sole,  and  lowering  of  the  arch — may 
be  fully  developed.  The  changes  of  the  bones  do  not  differ  essen- 
tially from  those  described  in  acquired  flat-foot.     The  deformity  may 


554  ORTHOPEDIC  SURGERY. 

be  spoken  of  as  congenital  flat-foot,  from  which  it  is  not  to  be  dis- 
tinguished. 

Acquired  Talipes  ]^algits  is  a  condition  characterized  by  eversion  of 
the  sole  of  the  foot  or  abduction  of  the  front  of  the  foot  in  relation  to 
its  long  axis,  or  by  both.  It  differs  from  acquired  flat-foot  in  the  ab- 
sence of  a  distinct  dropping  of  the  arch  of  the  foot.  This  distinction 
is  not  to  be  made  in  all  cases  nor  is  it  of  great  importance,  but,  in  gen- 
eral, cases  presenting  the  two  first  conditions  mentioned  are  to  be 
classed  as  valgus,  and  cases  with  the  dropping  of  the  arch  also  as  flat- 
foot.  The  most  common  cause  of  acquired'  talipes  valgus  is  anterior 
poliomyelitis.  It  also  occurs  in  hysteria,  following  inflammation  of  the 
ankle-joint,  and  in  certain  cases  of  spasm  of  the  peroneal  muscles. 
The  symptoms,  as  contrasted  with  those  of  flat-foot,  are  generally  char- 
acterized by  less  pain,  and  the  modification  in  the  gait  produced  by  the 
abnormal  position  is  in  general  more  prominent  than  pain. 

The  treatment  of  the  condition  consists  in  the  application  of  an  ap- 
paratus (Chapter  XXI.,  31)  to  correct  the  rolling  inward  of  the  ankle, 
combined  generally  with  some  support  to  the  arch  of  the  foot.  In  the 
milder  cases  the  application  of  a  flat-foot  plate  would  be  sufficient  treat- 
ment. 

TALIPES  VARUS. 

Talipes  varus  is  the  name  given  to  a  condition  in  which  the  sole  of 
the  foot  is  turned  inward.  Simple  talipes  varus  occurred  eighty-five 
times  in  sixteen  hundred  and  sixty  congenital  deformities  of  the  foot. 
In  its  congenital  form  the  deformity  is  apparently  an  incomplete  vari- 
ety of  ordinary  club-foot  in  which  the  element  of  equinus  is  not  marked. 
In  the  acquired  form  it  results  from  infantile  paralysis  and  is  at  times 
seen  as  the  result  of  severe  knock-knee.  As  associated  with  talipes 
equinus  it  is  the  commonest  of  congenital  deformities  of  the  foot. 

Treatment. — In  the  congenital  form  the  treatment  is  practically  the 
same  as  that  of  equino-varus,  except  that  it  may  not  be  necessary  to 
cut  the  tendo  Achillis.  In  the  acquired  form  retentive  apparatus  is 
useful,  preventing  eversion  of  the  foot  (Chapter  XXI.,  30). 

TALIPES  CAVUS. 

{Hollow  foot.  Pes  cavus.  Pes  arcuatus  or  excavatus,   Pied  hot  talus. 

Pied  creux,  Hohlfuss.) 

Talipes  cavus  is  the  name  given  to  a  condition  in  which  the  arch  of 
the  foot  is  increased  and  the  anterior  part  of  the  foot  is  approximated 
to  the  heel.  It  is  not  necessarily  associated  with  any  other  deformity, 
but  may  occur  in  connection  with  talipes  equinus,  calcaneus,  valgus  or 


TALIPES. 


555 


varus.  It  is  rarely  congenital  in  its  severe  forms,'  but  a  markedly 
high  arch  to  the  foot  may  be  an  inherited  peculiarity  sometimes  suf- 
ficiently marked  to  justify  classing  it  as  pathological.  In  the  acquired 
form  it  exists  in  most  cases  as  the  result  of  anterior  poliomyelitis, 
and  is  also  to  be  classed  as  a  shoe  deformity.  The  pathological 
changes  show  nothing  besides  the  effects  of  a  continued  malposition 
of  the  bones.  The  deformity  varies  more  or  less  in  degree.  The  most 
marked  form  is  to  be  found  in  the  foot  of  the  Chinese  lady  of  high  rank, 
in  which  the  heel  and  front  of  the  foot  are  approximated  by  bandaging 
in  early  youth,  and  a  degree  of  pes  cavus  is  induced  which  does  not 
exist  except  under  these  highly  artificial  conditions.     From  this  ex- 


FlG.  498. — Pes  Cavus  with  an  Element  of  Calcaneus. 

treme  grade  all  degrees  of  the  affection  are  seen,  the  slightest  being  an 
increased  elevation  of  the  arch  not  accompanied  by  symptoms,  in  which 
the  foot  rests  upon  the  ground  in  standing,  touching  only  on  the  heel 
and  ball  of  the  foot.  It  is  less  disabling  than  pes  calcaneus,  and  is  fre- 
quently associated  with  the  other  deformities  mentioned.  The  two 
types  commonly  seen  are,  first,  those  resulting  from  anterior  poliomye- 
litis, in  which  a  paralysis  more  or  less  extensive  has  involved  the  foot 
and  leg.  In  a  second  form,  generally  milder  in  grade,  it  apparently  de- 
velops as  a  shoe  deformity  in  middle  childhood,  and  appears  to  be  the 
result  of  wearing  too  short  a  shoe  or  of  a  shoe  narrower  than  the  front 
'  Redard  :  "  Chir.  orth.,"  p.  S39. 


556  ORTHOPEDIC  SURGERY. 

of  the  foot ;  the  front  of  the  foot  being  held  back  by  the  front  of  the 
boot,  the  tendency  in  weight-bearing  is  to  approximate  the  heel  and  the 
toe,  and  in  this  way  to  approximate  the  front  of  the  foot  to  the  heel. 
In  the  slightest  grade  it  apparently  forms  one  of  the  varieties  of  the 
condition  described  as  contracted  foot.  The  plantar  fascia  is  contracted 
and  bands  may  be  felt  under  the  skin.  The  symptoms  in  the  slighter 
varieties  are  those  of  a  sprain  of  the  arch  of  the  foot  and  the  muscles  of 
the  leg,  owing  to  insecure  balance  of  the  foot  in  standing.  Corns  and 
callosities  may  develop  in  the  front  of  the  foot ;  the  elasticity  of  the 
gait  is  impaired. 

The  treatment  of  the  slighter  forms,  in  which  the  symptoms  are 
due  to  the  imperfect  balance  of  the  foot,  consists  in  the  use  of  a  boot 
with  sufficient  room  in  front  and  of  proper  length,  which  is  pro\-ided 
with  a  high  arch  or  artificially  high  shank,  to  give  the  foot  a  correct 
bearing  surface  and  to  contribute  to  its  stability.  If  any  element  of 
equinus  coexist,  the  gastrocnemius  muscle  must  be  stretched.'  In 
cases  of  average  severity  in  young  children  a  flat  steel  plate  running 
the  length  of  the  boot  may  be  inserted  between  the  layers  of  the  sole, 
and  the  dorsum  of  the  foot  strapped  down  to  it  by  a  strap  running  over 
the  top  of  the  foot  and  fastening  to  the  plate.  This  will  tend  to  stretch 
the  contracted  tissues  in  walking.  Operation  is  required  in  the  severer 
cases.  The  plantar  fascia  is  thoroughl}'  divided  by  a  subcutaneous  te- 
notomy and  the  foot  put  up  in  a  plaster  bandage  which  should  flatten 
the  arch  of  the  foot  as  much  as  possible.  When  walking  is  begun, 
which  should  be  as  early  as  possible  after  operation,  the  steel  sole  plate 
and  strap  described  above  should  be  adjusted  to  the  shoe. 

CLUB-HAND. 

In  German  the  distortiDU  is  known  as  Khnnphaud,  and  in  French 
as  main  bote. 

Congenital  club-hand  is  a  rare  condition,  which  is  in  man}'  cases 
analogous  to  congenital  club-foot.  The  name  is  applied  to  a  deviation 
of  the  hand,  at  the  wrist,  from  the  line  of  the  forearm ;  this  deviation 
is  almost  always  in  the  direction  of  flexion. 

It  occurs  at  times  without  malformation  of  bones,  in  which  cases 
there  may  be  also  stiffness  of  the  shoulder-  and  elbow-joints  of  the 
affected  arms,  with  imperfect  development  of  the  muscles.  At  other 
times  there  is  associated  with  the  club-hand  an  absence  or  defective 
development  of  the  radius  or  ulna,  often  associated  with  other  malfor- 
mations. \\\\h  the  defective  development  of  the  bones  of  the  forearm 
are  likely  to  be  associated  muscular  defects  and  anomalies. 

Varieties. — The  modern  classification  of  the  distortion  is  to  speak 
of  the  cases  as  palmar  and  dorsal  club-hand,  as  the  deformity  is  toward 
'  Shaffer:  X.  Y.  Med.  Jour.,  March  5th.  1SS7. 


TALIPES. 


557 


flexion  or  extension ;  or  as  radial,  and  ulnar  or  cubital,  as  the  deviation 
is  imvard  or  outward  at  the  wrist.  Mixed  forms  are  the  most  common, 
and  are  spoken  of  as  radio-palmar,  etc.  The  dorsal  forms  are  rare. 
The  bones  of  the  arm  may  be  normal,  but  more  commonly  they  are 
deformed,  or  the  radius  may  be  wanting"  wholly  or  in  part.  The  carpus 
may  be  normal,  or  incompletely  developed,  or  almost  entirely  wanting. 
When  the  radius  is  deficient,  the  lower  end  of  the  ulna  is  enlarged  to 


Fig.   499. — Club-hand  Due  to  Congenita]  Absence  of  Radius.     (Sayre.) 

articulate  with  the  carpus.  A  variety  of  anomalies  of  the  muscles,  ves- 
sels, and  nerves  may  occur. 

Etiology. — No  satisfactory  etiological  cause  can  be  assigned  for  the 
occurrence  of  club-hand,  beyond  the  usual  explanations  urged  to  ac- 
count for  congenital  deformities  in  general. 

Symptoms. — In  looking  at  the  palmar  varieties  of  club-hand  it  is 
seen  that  the  wrist  is  sharply  flexed,  and  that  perhaps  the  lower  end  of 
the  radius  may  be  covered  by  the  skin  and  traversed  by  the  extensor 
tendons,  while  the  carpus  articulates  with  the  under  surface  of  the 
radius.  The  forearm  is  wasted,  and  if  the  radius  is  absent  it  appears  to 
be  very  slender  indeed.  The  hand  possesses  a  certain  degree  of  mobil- 
ity at  the  wrist,  and  when  it  is  partly  replaced  the  flexor  tendons  can  be 
felt  to  be  rendered  tense,  and  stand  out  under  the  skin. 


558  ORTHOPEDIC  SURGERY. 

The  diagnosis  is  evident,  and  any  pathological  process  \Yhich  is  ac- 
companied by  this  malposition  is  classified  as  club-hand. 

Treatment. — In  the  mildest  cases,  particularly  if  the  bony  structure 
is  normal,  treatment  should  consist  of  manipulation  to  stretch  the  con- 
tracted tissues  and  retention  in  the  correct  position  by  means  of  a 
splint. 

Tenotoni}'  is  to  be  done  only  if  reposition  is  impossible  without  it. 
After  retention  in  the  proper  position  for  a  sufficient  time,  massage  and 
muscle  training  should  be  begun. 

Where  bony  defects  are  present  and  the  case  is  not  to  be  rectified 
by  the  measures  described,  some  operation  on  the  bone  may  be  per- 
formed. R.  H.  Sayre '  performed  an  osteotomy  of  the  ulna  to  correct 
its  curve,  and  later  removed  two  of  the  carpal  bones  and  the  styloid 
process  of  the  ulna  and  inserted  the  end  of  the  ulna  into  the  gap  in 
the  carpus.  Thompson"  removed  a  wedge  from  the  lower  part  of  the 
ulna.  McCurdy  divided  the  ulna  across  and  sutured  the  distal  end  to 
the  semilunar  bone.^  Bardenheuer  ^  has  split  the  lower  end  of  the  ulna 
longitudinally  and  implanted  the  carpus  between  the  two  parts  of  the 
ulna  separated. 

The  reported  results  of  these  operations  have  been  favorable,  but  it 
must  be  evident  that  the  joint  under  these  conditions  must  be  an  im- 
perfect one.' 

'Trans.  Am.  Orth.  Assn.,  vol.  vi..  p.  208. 

"Ibid.,  vol.  ix..  p    165. 

'^ Ibid.,  vol.  viii.,  p.  8. 

•'\'erhandlung  der  deutschen  Gesellschaft  f.  Chir..  1894= 

^Kirmisson:  "Mai.  Clin.  d'Origine  Congen  ,"  189S. 


CHAPTER    XX. 


FLAT-FOOT   AND 


OTHER   DEFORMITIES    OF 
FOOT. 


THE 


Flat-foot  (Definition. — Patliology. — A'arieties. — Causation. — Frequency. — Sj'mp- 
toms. —  Diagnosis. — Prognosis.  —  Treatment). — Anterior  metatarsalgia. — Hal- 
lux valgus. — Hallux  varus. — Hallux  rigidus. — Hammer  toe. — Clawed  toes. — 
Painful  heel. — Post-calcaneal  bursitis. — Synovitis  of  tendo  Achillis. — Exos- 
toses. 

FLAT-FOOT. 

Definition. — The  term  "flat-foot"  is  applied  to  a  deformity  usually 
of  a  static  type — that  is,  one  due  to  superimposed  weight.    Thisdeform- 


FlG.  500. — Print  of  Child's  Foot  in  Mocca- 
sin, Showing  Weight- bearing  Portion  of 
Foot. 


Fig.  501. — Foot  of  Japanese  Bronze. 
(Boston  Art  ^Museum.) 


ity  resembles  in  many  respects  talipes  valgus,  and  has  been  consid- 
ered by  many  wTiters  a  variety  of  that  distortion.  There  is,  however, 
sufficient  difference  to  warrant  a  consideration  of  flat-foot  by  itself. 

559 


56o 


ORTHOPEDIC  SURGERY. 


The  abnormality  of  flat-foot  is  best  understood  by  a  comparison  with 
the  normal  standard. 

Normal  Foot. — If  the  foot  of  a  yoang  infant  is  examined  it  will  be 


Fig.  502.— Feet  of  Charioteer 


Fig.  503.  — Egyptian  Statue. 


seen  that  there  is  muscular  power  in  the  movement  of  all  of  the  toes. 
The  great  toe  can  voluntarily  be  drawn  to  the  inner  side,  and  the  fifth 


FLAT-FOOT  AND    OTHER  DEFORMITIES.  561 

toe  can  be  drawn  to  the  outer  side  by  voluntary  muscular  exertion. 
The  toes  can  be  flexed  readily.  The  second  toe  is,  when  stretched  to 
its  full  length,  frequently  longer  than  the  first.  The  third  is  of  the 
same  length  as  the  first,  the  fourth  is  somewhat  shorter,  and  the  fifth, 
though  shorter,  is  but  slightly  so.  None  of  the  toes  remains  perma- 
nently curled,  though  when  in  a  relaxed  condition  the  terminal  phalanx 
drops  somewhat  and  the  smaller  toes  curl.  A  separation  between  the 
first  and  second  toe  is  normal.  When  the  muscles  are  active  the  great 
toe  is  drawn  to  the  inner  side  frequently.  The  line  of  the  extremities 
of  the  toes  presents  a  gradual  curve  with  the  greatest  forward  con- 
vexity at  the  tip  of  the  second  toe.  The  line  of  the  inner  edge  of  the 
foot  is  always  straight  except  when  there  is  contraction  of  the  muscles. 


Fig.  504.— Left  Foot  of  Child  Eighteen  Mouths  Old.     (Dane.) 

If  the  undistorted  adult  foot  which  has  never  worn  shoes  be  exam- 
ined, it  will  be  found  to  present  many  of  the  characteristics  of  the 
infant's  foot,  but  there  is  greater  muscular  power  in  the  toes  and  foot 
and  relatively  less  fatty  tissue.  The  flexibility  of  the  front  of  the  foot 
is  great,  and  can  be  increased  by  training,  especially  in  the  power  of 
separating  the  great  toe  from  the  next,  which  is  utilized  as  an  aid  in 
prehensibility. 

If  in  comparison  the  foot  of  an  adult  who  has  always  worn  shoes  is 
studied,  a  loss  of  flexibility  in  the  movements  of  the  toes,  often  some 
distortion  of  the  front  of  the  foot,  and  an  impairment  of  muscular  power 
of  the  muscles  of  the  foot  are  seen.  The  effect  of  this  impairment  is 
to  favor  the  development  of  the  deformity  generally  known  as  flat-foot. 

Pathology. — In  light  cases  of  flat-foot  the  anatomical  changes  show 
very  few  alterations  in  the  shape  of  the  bones.  There  is  simply  an 
altered  relativ^e  position.' 

^"Statik  und  Mechanik  des  menschl.  Fusses,"  Zeit.  f.  orth.  Chir.,  1894,  iii., 
243.— R.  W.  Lovett  and  F.  J.  Cotton:  Trans.  Am.  Orth.  Assn.,  vol.  xi.— Peter- 
sen:  Arch.f.  Orth.  (abst.),  i.,  3. — Riedinger:  Centralbl.  f.  Chir.,  1897,  No.  15. — v. 
Meyer :  "  Ursache  und  Mechanismus  der  Entstehung  des  erworbenen  Plattfusses," 
Jena.  1883. 

^.6 


562 


ORTHOPEDIC  SURGERY. 


The  nature  of  the  mechanism  of  the  deformity  will  be  better  under- 
stood if  the  normal  action  of  the  foot  in  standing  and  walking  is  borne 


Fig.  505. — Savage  Feet. 

in  mind.  If  an  individual  with  normal  feet  stands  with  both  feet 
placed  together  and  pointed  forward,  the  weight  in  each  foot  falls  upon 
a  point  midway  between  the  outer  and  inner  edge,  passing  through  the 


FLAT-FOOT  AND    OTHER  DEFORMITIES. 


563 


ankle  and  astragalus  and  being  distributed  to  the  rest  of  the  foot.  If 
now,  the  superimposed  weight  is  made  excessive  by  havmg  the  individ- 
ual stand  upon  one  foot,  the  body  inclines  to  that  sMde  to  preserve  the 


=*^ 


Fig.  506.— Longitudinal  Section  of  Foot.      (Fick.) 

balance  and  to  prevent  side  strain.  When  the  weight  upon  the  foot 
comes  in  such  a  way  that  it  cannot  be  brought  directly  over  the  middle 
of  the  foot,  a  movement  takes  place  whereby  the  side  strain  is  dimin- 
ished. This  represents  the  position  of  muscular  strength  when  exposed 
to  the  strain  of  excessive  superimposed  weight.     In  this  movement  the 


564 


ORTHOPEDIC  SURGERY. 


astragalus  and  ankle  are  pulled  sideways  to  the  outer  side  of  the  foot, 
the  ball  of  the  foot  and  the  heel  being  placed  firmly  on  the  ground  and 
the  astragalus  being  held  firmly  from  lateral  motion  by  the  tibia  and 
the  fibula.  This  motion,  which  is  made  possible  by  the  many  articu- 
lations of  the  foot,  occurs  in  the  midtarsal  joint  chiefly.  The  scaphoid, 
the  inner  cuneiform,  and  the  posterior  end  of  the  first  metatarsal  are 


Pig.  507. 


-Posterior  View  of  Foot,  Showing  Ligamentous  Support  and  its  Weakness  to 
Strain  Inward.     (Fick.) 


"brought  upward  and  to  the  outer  side,  the  great  toe  and  the  head  of  the 
first  metatarsal  are  pressed  firmly  on  the  ground,  and  the  os  calcis  and 
the  cuboid  move  with  the  astragalus. 

In  contrast  with  this  movement  of  strength  and  muscular  support 
must  now  be  con%\dQ\-&d  the  position  of  relaxation  and  ineffectual  sup- 
port. When  the  patient  is  standing,  if  the  muscles  moving  the  great 
toe  and  the  head  of  the  first  metatarsal  or  those  regula'ting  the  outward 
and  upward  movement  of  the  inner  side  of  the  scaphoid  are  weak  or 


FLAT-FOOT  AND    OTHER  DEFORMITIES. 


565 


inefficient  or  do  not  act  with  strength,  the  midtarsus  drops  to  the  inside 
when  superimposed  weight  falls  upon  it,  and  the  movement  is  the  re- 
verse of  that  described  above.  The  astragalus  rotates  inward;  the 
scaphoid,  the  cuneiform,  and  the  proximal  end  of  the  first  metatarsal 
move  downward  and  inward ;  and  the  front  end  of  the  os  calcis  and  the 
cuboid  follow  the  astragalus  to  the  side.  This  involves  a  twisting  of 
the  whole  limb,  which  rotates  at  the  hip-joint.  The  astragalus  moving 
with  the  leg  on  the  bones  of  the  foot,  the  inner  malleolus  will  in  conse- 
quence be  seen  to  move  downward,  inward,  and  backward.  Up  to  a 
certain  limit  this  movement  occurs  in  relatively  normal  feet,  but  be- 


FlG.  508.— Pr.nt  of  Arab  Foot. 


Fig.  509.— Plaster  Cast  of  Dental  Wax  Foot 
Impression  in  Sand,  Showing-  Weight- 
bearing  Portions  of  Foot. 


yond  this  what  must  be  regarded  as  a  pathological  condition  is  reached, 
attended  by  symptoms  of  pain  and  disability,  and  is  the  first  step  in  the 
formation  of  flat-foot. 

The  deformity,  strictly  speaking,  is  not  a  flattening  of  the  foot,  but 
consists  of  an  exaggerated  midtarsal  drop  and  twist,  occurring,  as  has 
been  said,  normally  under  certain  conditions.  The  deformity  is  a  com- 
bination of  inward  rolling  and  dropping  to  the  inside  of  the  middle  of 
the  foot,  with  an  outward  deviation  of  the  front  of  the  foot.  Normally 
in  the  standing  position,  if  the  patella  faces  straight  to  the  front,  the 
foot  should  be  directed  also  straight  ahead ;  but  in  flat-foot  the  front  of 
the  foot  turns  to  the  outside  when  the  leg  is  placed  with  the  patella 


566 


ORTHOPEDIC  SURGERY. 


and  ankle  squarely  to  the  front.  The  deformity  has  for  this  reason 
been  termed  pronated  foot,  as  the  deformity  somewhat  resembles  pro- 
nation.    It  is  also  called  weak  or  weakened  foot. 


Fig.  510. — Casts  of  Civilized  and  of  Savage  Feet. 

There  is  necessarily  a  variation  in   the  relative  prominence  of  the 
different  factors  of  the  deformity   in  individual  feet:    i.  The  inward 


Fig.  sii.— Voluntary  Plantar  Flexion  (Nor- 
mal).    (Whitman.) 


Fig.  512.— Voluntary  Dorsal  Flexion  (Nor- 
mal).    (Whitman.) 


movement  of  the  midtarsus,  "  the  dropping  in  "  of  the  foot,  may  be  the 
characteristic  of  some  cases.     2.  The  dropping  down  of  the  arch  may 


FLAT-FOOT  AND    OTHER   DEFORMITIES.  567 

be  the  most  prominent  feature  in  others.  3.  The  abduction  of  the 
front  of  the  foot,  resulting  in  a  change  of  the  angle  between  the  front 
of  the  foot  and  the  axis  of  the  heel,  may  characterize  still  other  cases. 
And  these  three  factors  may  be  present  in  varying  proportions  and 


Fig.  513.— Weakened  Foot  without  Breaking  Down  of  Arch. 

relations.     The  recognition  of  the  relative  prominence  of  these  elements 
is  of  much  importance  in  treatment. 

Alterations  in  the  shape  of  the  bones  are  noted,  in  severe  cases  the 


Fig.  514. — Meyer's  Line  in  Average  Foot. 


Fig.  515.— Meyer's  Line  in  Normal  Foot. 


external  malleolus  being  at  times  somewhat  flattened  and  rounded. 
The  chief  distortion  in  the  bones  occurs  in  the  astragalus,  os  calcis, 
scaphoid,  and  cuboid.  In  extreme  cases  the  astragalus  has  dropped 
from  above  to  the  inside  of  the  os  calcis,  the  latter  being  rolled  to  the 


508 


ORTHOPEDIC  SURGERY. 


inside  with  a  deviation  of  its  forward  end  to  the  inside.      The  front  of 
the  foot  is  turned  outward,  the  scaphoid  and  cuboid  being  practically 


I'lG.  510.—  iable  wiLu  (jiuss  Top  for  Examining  Feet. 


Fig.  517.— Glass  Table  for  Examining,  in  Use  with  Mirror. 

dislocated.  At  the  outer  side  the  cuboid  may  be  displaced  upward. 
Changes  in  the  direction  of  the  metatarsus  and  of  the  phalanges  are 
found.     Exostoses  are  frequently  developed. 

There  is  a  loss  of  the  normal  play  of  the  bones  in  the  tarsal  articu- 


FLAT-FOOT  AND    OTHER  DEFORMITIES.  569 

lations  from  loss  of  elasticity  of  the  ligaments,  and  changes  in  the 
shape  of  the  bones  result  from  abnormal  pressure. 

The  muscles  are  changed  in  their  strength,  the  tibialis  being  weak- 
ened and  the  peronei  contracted. 

The  plantar  ligaments  are  stretched  and  displaced,  and  those  bear- 
ing strain  are  thickened. 

Varieties. — As  has  been  already  mentioned,  talipes  valgus  resem- 
bles flat-foot,  and  they  are  often  classed  together.     For  clinical  rea- 


FlG.  51S. — Type  of  Tracing  Described  as  Normal. 

sons  it  is  more  convenient  to  consider  the  subjects  separately.  The 
same  is  also  true  of  congenital  valgus,  sometimes  called  congenital  flat- 
foot. 

Infants  were  thought  to  be  flat-footed,  but  this  has  been  shown  to 
be  apparent  rather  than  real.' 

Causation. — In  general  terms  it  may  be  said  that  the  deformity  is 
caused  by  a  disproportion  between  the  weight  to  be  borne  and  the  mus- 
cular power  which  bears  it.  Among  the  determining  causes  may  be 
mentioned : 

1.  Boots  of  improper  shape  or  size. 

2.  Weakness  or  insufficiency  of  the  muscles,  resulting  from  ill 
health  and  especially  following  confinement. 

'  Dane:  Trans.  Am.  OrtliOp.  Assn.,  1898.  —  Spitzy  :  Zeitschrift  f.  orth.  Chir,,, 
xii.,  4,  777. 


570 


ORTHOPEDIC  SURGERY. 


3.  Prolonged  standing. 

4.  Rapid  growth. 

5.  Rapid  increase  in  weight. 

6.  Accident  or  disease,  causing  disuse  of  Hmb  and  muscular  weakness. 


Fig.  519. -Flat-fool  Occurring  in  a  Young  Rhachitic  Child. 

7.  Excessive  weight-bearing,  as  in  the  case  of  professional  strong 
men  and  jumpers. 

8.  A  shortened  condition  of  the  gastrocnemius  muscle,  as  described 


Fig.  520. — Outline  Drawing  (from  Photo- 
graph), Showing  Inward  Excursion  of 
Internal  Malleolus  in  Pronaiion. 


Fig.  521. —  Composite  Photograph,  Showing 
Excursion  of  Malleolus  and  Arch  with  and 
without  Weight-bearing.     (Dane.) 


by  Shaffer.  Unless  dorsal  flexion  of  the  foot  beyond  a  right  angle  is 
possible,  it  is  difficult  for  a  person  to  complete  the  step  with  the  leg 
straight  behind  him  and  the  foot  pointing  forward.     Eversion  of  the 


FLAT-FOOT  AND    OTHER  DEFORMITIES. 


571 


foot  is  necessary,  and  a  completion  of  the  step  by  rolling  over  on  to  the 
inner  side  of  the  foot. 

9.  Rickets,  distorting  the  bones  of  the  foot. 

10.  Infantile  paralysis. 

1 1 .  Spastic  paralysis  or  other  disturbances  of  muscular  balance. 

12.  Trauma  and  inflammation. 

The  most  common  of  traumatic  causes  is  Pott's  fracture,  m  which  a 
deformity  is  the  result  of  inefficient  treatment  or  of  a  very  severe  and 
intractable  fracture.  As  a  result 
of  ankle-joint  disease  accompa- 
nied by  considerable  destruction 
of  tissue,  one  sometimes  sees 
very  marked  flat-foot,  which  does 
not  tend  to  grow  worse,  because 
there  is  generally  firm  ankylosis 
in  the  ankle;  but  the  deformity 
may  be  severe.  Acute  arthri- 
tis, especially  of  gonorrhoeal 
origin,  is  a  not  infrequent  cause 
of  flat-foot. 

Causation.— Flat-foot  has 
been  mentioned  as  a  race  pecul- 
liarity,  negroes  and  Jews  being 
mentioned  as  especially  afflicted ; 
but  facts  do  not  warrant  the 
statement,  which  has  been  found 
not  to  be  true  of  the  native 
negroes  of  Africa.' 

Many  of  the  barefooted  races 
have  been  considered  flat-footed 
simply  because  of  the  strong 
development  of  the  muscles  of 
the  sole,  careful  examination 
showing  excellent  arches. 

The  most  common  cause  is  the 
weakening  of  the  muscles  of  the 

foot  by  shoes.  Shoes  as  worn  by  the  leisure  class  or  by  the  class  that 
gain  their  livelihood  (as  is  the  rule  in  cities)  by  occupations  which  re- 
quire standing  rather  than  strong  and  vigorous  walking,  compress  the 
front  of  the  foot.  This  part  of  the  foot,  from  compression  and  from 
resulting  weakness,  cannot  adapt  itself  as  greater  weight  is  thrown 
upon  the  foot,  and  the  medio-tarsal  twisting  takes  place,  which  in  the 
strong  bare  foot  is  prevented  chiefly  by  the  action  of  the  tibial  muscles 
^  Freiberg:  Am.  Journ.  of  Orth.  Surgery,  vol.  i. 


Fig.  522.  —  Composite  Photograph,  Showing 
Lateral  Excursion  of  Lower  Leg  and  Foot 
with  and  without  Weight-bearing.     (Dane.) 


572 


ORTHOPEDIC  SURGERY. 


and  by  the  muscles  of  the  first  metatarsal  and  its  phalanges.  People 
the  front  of  whose  feet  has  been  compressed  stand  and  walk  with  a 
greater  angle  of  divergence  of  the  axes  of  the  feet,  which  increases  the 
danger  of  the  development  of  the  deformity  by  bringing  greater  strain 
upon  the  inner  side  of  the  foot  and  favoring  the  inward  rolling  which 
frequently  develops  flat-foot.  Flat-foot  is  not  developed  among  moc- 
casined  savages  who  use  their  feet  actively  as  hunters,  using  the  mus- 
cles of  the  front  of  the  foot  freely. 

Symptoms. — Flat-foot  is  a  deformity  characterized  by  a  flattened 
appearance  of  the  sole  of  the  foot. 

The  deformity  is  also  called  splay-foot,  pes  planus,  and  spurious  val- 


FiG.  523. — Tracing  of  a  "  Flat  foot."    No  symptoms. 

gus;  in  German,  Plattfuss;  and  in  French,  pied  plat.     It  is  also  some- 
times called  pes  pronatus. 

It  can  for  convenience  clinically  be  divided  into  two  groups : 

1.  Flexible  flat-foot  or  zucakencdfoot,  where  little  or  no  structural 
changes  have  taken  place  and  the  foot  assumes  the  flattened  position 
only  when  weight  falls  upon  it. 

2.  Rigid  flat-foot  or  flat-foot  proper,  in  which  the  distortion  is  per- 
manent, some  structural  change  in  Hgament  or  bone  having  taken  place. 

In  Blodgett's '   series  of  one  thousand  cases  the  females  predomi- 
nated, and  two-thirds  o^  the  cases  were  under  forty  years  of  age. 
'W.  E.  Blodgett:  Am.  Journ.  of  Orth.  Surgery,  vol.  ii.,  No.  2. 


FLAT-FOOT  AND   OTHER  DEFORMITIES. 


573 


Deformity. — In  the  severer  cases,  instead  of  the  normal  arching 
upward  of  the  inner  border  of  the  foot,  this  border  is  either  less  arched 
than  normal  or  is  in  contact  with  the  ground.  The  foot  has  the  appear- 
ance of  being  not  only  broad  but  abnormally  long.  It  is  more  or  less 
everted,  and  in  severe  cases  the  head  of  the  astragalus  and  the  scaphoid 
tubercle  form  a  marked  bony  prominence  at  the  middle  of  the  inner 
border  of  the  foot.  The  internal  malleolus  is  more  prominent  than 
normal  and  is  thought  by  the  patient  to  have  enlarged.  In  the  milder 
cases,  which  are  often  too  slight  properly  to  deserve  the  name  flat-foot, 
there  is  the  beginning  of  a  similar  process.     This  beginning  abnormal- 


FiG.  524. — Flat-foot  of  Moderate  Degree. 


ity  of  position,  although  sufficient  to  cause  symptoms,  may  be  so  slight 
as  to  escape  observation  except  on  the  closest  inspection.  There  is  a 
tendency  of  the  inner  malleolus  to  be  more  prominent,  the  foot  is 
slightly  everted,  the  weight  is  borne  more  on  the  inner  border  than 
is  normal,  and  the  arch  of  the  foot  may  appear  to  be  somewhat  lower 
than  normal.  This  condition  might  perhaps  be  better  spoken  of  as  a 
strained  than  as  a  flattened  foot;  from  this  condition  to  that  of  a  com- 
pletely flattened  foot  every  degree  is  to  be  seen  clinically.  Marked 
flat-foot  may  be  present  without  causing  symptoms.  It  is  not  infre- 
quently seen  in  athletes  and  occurs  as  a  perfectly  useful  foot  m  a  cer- 


574 


ORTHOPEDIC  SURGERY. 


tain  small  proportion  of  persons.     In  such  cases  the  foot  is  flexible; 
when  structural  changes  have  taken  place  in  the  ligaments,  muscles,  or 
bones,  and  stiffness  is  present,  painful  symptoms  are  generally  seen. 
Flat-foot  is  more  frequently  double  than  single,  and  as  a  rule  the 


Fig.  525.— Severe  Double  Flat-foot. 

symptoms  in  one  foot  are  more  severe  than  those  in  the  other.     The 

symptoms  are  frequently  worse  in  the  foot  showing  the  least  deformity. 

Pain. — The  first  SN-mptom  complained  of  is  a  sense  of  discomfort  in 

the  feet  after  standing  or  walking.     This  may  increase  until  pain  of 

greater  or  less  extent  is  present  during 
and  following  use  of  the  feet.  In  the 
milder  cases  pain  ceases  when  the  weight 
is  removed,  but  as  the  condition  be- 
comes more  advanced  the  pain  not  only 
becomes  more  severe,  but  continues 
after  the  use  of  the  feet  is  stopped, 
and  in  the  severer  cases  persists  during 
part  of  the  night.  The  severity  of  the 
pain  may  be  greater  than  is  to  be  ex- 
pected from  the  amount  of  distortion. 
The  pain  is  most  frequent  in  the  neigh- 
borhood of  the  scaphoid ;  it  occurs  also 
in  the  front  of  the  foot,  in  the  centre  of  the  heel,  behind  the  inner 
malleolus,  and  on  the  outer  border  of  the  foot.  Pain  is  also  complained 
of  in  connection  with  flat-foot  in  certain  cases  in  the  leg,  knee,  back, 
or  hip. 

Tenderness. — Tenderness    is    seen    over  Doints   of    ligamentous 


Fig.  526. — Outline  Drawing  (from  Pho- 
tograph) in  Normal  and  Pronated 
Position.  Showing  Forward  Excur- 
sion of  Mark  over  E.xternal  Malleo- 
lus in  the  Pronated  Position. 


FLAT-FOOT  AND   OTHER  DEFORMITIES.  575 

strain ;  it  occurs  under  the  scaphoid,  under  the  centre  of  the  heel,  be- 
hind the  internal  malleohis,  at  the  outer  border  of  the  foot,  and  in  the 
great  toe-joint.  It  is  rarely  absent  and  may  be  found  in  one  or  more  of 
these  situations,  according  to  the  type  of  the  distortion. 

Muscular  Spasm. — In  very  acute  cases  there  may  be  irritability 


Fig.  527.— Displacement  of  Little  Toe.     (H.  L.  Burrell.) 

and  contraction  of  the  peroneal  muscles  holding  the  foot  in  the  position 
of  abduction ;  in  this  case  there  is  apt  to  be  tenderness  over  the  origin 
of  the  peroneal  muscles.     Irritability  of  the  gastrocnemius  frequency 


a  J) 

Fig.  52S.-a,  Flat-foot ;  b,  Flat-foot  with  Eversion.     (Children's  Hospital  Report.) 

exists,  and  tenosynovitis  of  the  tibial  and  peroneal  muscles  is  occasion- 
ally seen. 

Stiffness.— Congestion  of  the  foot  and  swelling  of  the  foot  and 
leg  are  frequent  symptoms.  Stiffness  or  loss  of  flexibility  is  a  symptom 
which  is  gradually  developed,  and  it  involves  at  first  and  most  promi- 


576 


ORTHOPEDIC  SURGERY. 


nentiy  the  mediotarsal  joint.  The  stiffness  is  such  that  the  front  of  the 
foot  cannot  be  adducted  actively  or  passively  as  much  as  it  normally 
should  be.  This  is  an  important  matter  to  recognize,  as  it  prevents  an 
assumption  of  a  correct  position  by  voluntary  muscular  effort  until  the 
proper  flexibility  is  restored.  There  is  also,  especially  in  the  later  his- 
tory of  the  case,  some  limitation  in  the  plantar  and  dorsal  flexion  of  the 
foot  at  the  ankle-joint.  •■ 

In  severe  flat-foot,  owing  to  the  change  in  the  form  of  the  bones, 
there  is  a  limitation  in  the  amount  of  motion  at  the  ankle-joint.  The 
normal  amount  of  motion,  which  should  be  80°,  in  flat-foot  may  be  re- 
stricted to  30°  or  40°. 

Gait. — The  gait  becomes  modified  as  the  affection  progresses  and 
becomes  in  a  measure  characteristic.      The  feet  are  generally  more 

everted  than  normal,  and  in  painful  cases  it 
will  be  noted  that  in  standing  the  patient 
deliberately  throws  the  foot  over,  so  that 
the  weight  is  borne  more  upon  the  inner 
border  than  is  normal.  There  is  a  lack  of 
elasticity  to  the  gait,  and  this  is  a  symptom 
often  complained  of  by  the  more  intelligent 
patients,  who  find  their  feet  stiff  and 
clumsy.  After  the  patient  has  been  sit- 
ting for  some  time  and  on  rising  in  the 
morning  the  feet  are  likely  to  be  stiff  and 
clumsy. 

Contracted  Foot. — Mention  should 
be  made  of  a  type  of  painful  affection  of  the 
foot  often  seen  in  practice,  in  which  the 
symptoms  of  muscular  irritability  and  con- 
traction predominate.  It  may  be  an  accom- 
paniment of  mild  flat-foot  or  it  may  exist 
in  connection  with  a  highly  arched  foot. 
Such  feet  cannot  be  dorsally  flexed  beyond  a 
right  angle,  and  perhaps  motion  may  be  restricted  in  other  directions. 
Pain  and  irritability  in  walking  may  be  noticed  in  the  calves  of  the  legs  as 
well  as  in  the  arches  of  the  feet,  and  even  backache  may  be  present. 
This  variety  of  irritable  and  strained  foot  is  probably  one  of  the  affec- 
tions described  as  "  contracted  foot  "  '  or  "  non-deforming  club-foot."  "" 
It  is  apparently  due  to  the  strain  and  bad  balance  induced  by  wearing 
improper  and  ill-fitting  shoes.  It  is  most  commonly  seen  in  women  of 
the  upper  classes. 

^Lovett:  Art.  "Orthopedic  Surgery,"  Park's  "System,"  2d  ed.— Whitman: 
"  Orth.  Surgery,"  2d  ed.,  p.  699. 

■^Shaffer:  N.  Y.  Med.  Rec.,May23d,  1885;  N.  Y.  Med.  Journ.,  March  5th,  1887. 


Fig.  529.  — Boot  for  Left  Foot 
Worn  by  Patient  with  Severe 
Flat-foot,  Showing  Character- 
istic "Treading-  Over  "  of  Shoe. 


FLAT-FOOT  AND    OTHER  DEFORMITIES.  577 

Symptoms  in  Children.-Ih  young  children  the  symptoms  are 
somewhat  modified.  Pain  is  not  a  common  symptom,  and  rigidity  in 
the  deformed  position  is  rare.  The  amount  of  flattening  is  on  the  aver 
age  greater  than  in  adult  cases  when  the  child  is  in  the  standin-  posi- 


Fig. 


53°-— Radiograph  Showing:  Compression  of  Left  Foot  by  Boot. 


tion.  The  child  tires  easily,  is  not  steady  in  walking  or  light  on  the 
feet  m  movements  requiring  balance,  and  falls  frequently.  Associated 
with  the  flattened  foot  there  is  often  to  be  found  in  young  children  an 
abnormal  lateral  mobility  of  the  knee-joints.' 

'  Journ.  Am.  Med.  Assn.,  April  i8th,  igoi 
37  ^' 


5/8 


ORTHOPEDIC  SURGERY. 


Diagnosis. — The  recognition  of  a  static  disturbance  in  the  foot  suffi- 
cient to  give  rise  to  pain  is  to  be  made  partly  from  the  history  of  the 
case,  and  partly  from  the  examination  of  the  foot.  The  characteristic 
symptoms  have  been  already  indicated. 

For  examination  of  the  feet,  the  shoes  and  stockings  should  be  re- 


m 

^^.: 


1'  ^'^  . 


Fig.  531.— Radiograph  Showing  Right  Foot  Uncompressed  by  Boot. 

moved  and  the  patient  should  stand  facing  the  surgeon  upon  the  floor 
or  upon  a  plate  of  glass  with  a  mirror  underneath. 

The  relation  of  the  foot  to  the  leg  should  be  noted,  whether  the  in- 
ternal malleolus  is  unduly  prominent  and  the  foot  rolled  over  on  to  its 
inner  border.     The  height  of  the  arch  of  the  foot  is  of  importance,  and 


FLAT-FOOT  AND    OTHFR   DEFORMITIES. 


579 


any  lowering  of  the  inner  border  is  significant.  The  rolhng  of  the 
foot  further  on  to  its  inner  side  or  the  lowering  of  the  arch  after  the 
patient  has  stood  for  a  minute  indicates  muscular  insufficiency  under 
weight-bearing. 

If,  in  addition  to  its  outline,  the  sole  of  the  foot  is  inspected  by 
means  of  the  mirror,  the  normal  foot  will  show  an  evenly  distributed 
anaemic  area,  the  weakened  foot  will  bear  more  weight  at  its  inner  sur- 
faces at  the  front  and  back  of  the  foot,  and  will  roll  over  further  under 
the  influence  of  muscular  fatigue. 

The  impression  of  the  weight-bearing  foot  is  of  interest,  but  not  of 
great  diagnostic  value.  In  the  tracing  as  ordinarily  taken  the  non- 
weight-bearing  position  of  the  foot  is  recorded  first  and  then  the  weight- 
bearing  position,  the  two  being  superimposed.     The  abnormal  and  the 


Fig.  532. — Xormal  Motion  of  the  Front  of  the  Foot. 

normal  imprints  are  shown  in  the  accompanying  illustrations.  The 
impression  of  the  foot  is  taken  by  having  the  patient  step  on  a  piece  of 
cardboard  blackened  with  camphor  smoke. 

The  degree  of  flexibility  should  be  examined  by  attempting  to  ad- 
duct  the  forefoot  gently  with  the  hands  and  to  flex  the  foot  dorsally 
with  the  patient's  knee  extended.  Loss  of  the  first  of  these  move- 
ments is  of  diagnostic  importance. 

The  presence  of  tender  points  in  the  sole  of  the  foot,  either  under 
the  heel  or  under  the  scaphoid,  generally  indicates  static  disturbance 
of  the  foot. 

The  range  of  variation  in  the  contour  of  the  foot  and  in  the  height 
of  the  arch  in  individual  feet  is  so  marked  that  from  inspection  it  is  not 
possible  to  say  that  a  foot  may  or  may  not  be  the  seat  of  symptoms. 
A  foot  apparently  anatomically  sound  may  give  rise  to  symptoms, 
while,  on  the  other  hand,  one  excessively  rolled  in  may  be  perfectly 
useful.' 

Differential  Diagnosis. — Rheiiinatisin  and  Arthritis  Deformans. — 
The  diagnosis  of  "  rheumatism  "  in  the  feet  should  be  made  with  very 
great  care  and  only  in  connection  with  distinctly  rheumatic  manifesta- 

^  Lovett:  "  The  Occurrence  of  Fiat-Foot  among  Trained  Nurses."  Am.  Journ 
Orth.  Surgery,  vol.  1,.  i. 


58o  ORTHOPEDIC  SURGERY. 

tions  in  the  upper  extremities.  Pain  in  the  knees,  hips,  and  back  may 
be  purely  secondary  to  a  static  disturbance  in  the  foot.  The  frequency 
with  which  this  diagnosis  is  made  by  practitioners  unfamiliar  with  flat- 
foot  makes  it  important  to  lay  much  stress  on  this  point.  The  fact 
that  no  dropping  of  the  arch  of  the  foot  can  be  detected  by  the  eye  by 
no  means  establishes  the  diagnosis  of  rheumatism. 

An  ,r-ray  examination  is  of  assistance  in  determining  any  displace- 
ment in  the  relation  of  the  bones  to  each  other  occurring  in  the  severer 
grades  of  the  affection  and  not  present  in  the  lighter  grades.  It  is 
also  of  value  in  giving  information  as  to  the  presence  of  arthritis  defor- 
mans and  the  existence  of  spurs  of  bones. 

Prognosis. — After  a  time  the  foot  may  become  accustomed  to  its 
altered  position  and  painful  symptoms  cease.  In  other  cases,  however, 
the  painful  symptoms  continue  and  become  worse  rather  than  better. 

The  condition  may  persist  almost  indefinitely,  a  constant  source  of 
pain  and  disability. 

The  results  of  treatment  are  as  a  rule  satisfactory.  In  cases  with 
little  permanent  distortion  but  great  muscular  weakness,  benefit  and 
cure  can  be  expected  from  careful  treatment.  In  cases  of  average 
severity,  relief  can  almost  always  be  given  by  very  simple  measures. 
A  spontaneous  cure  is  not  to  be  expected. 

Even  after  deformity  of  the  bone  takes  place  and  the  distortion  is 
confirmed,  a  useful  foot  may  be  obtained  if  the  muscular  developrnent 
of  the  leg  is  good.  Severe  deformity  can  be  corrected  by  operative 
measures,  with  the  restoration  of  normal  function  by  after-treatment. 

Treatment. — The  treatment  of  the  conditions  described  will  depend 
upon  the  nature  of  the  deformity,  its  severity,  and  its  duration. 

The  principles  of  treatment  are  simple.  They  consist  of  the  sup- 
port of  the  foot  in  a  proper  position  (if  support  is  needed)  and  the  de- 
velopment of  the  strength  of  the  muscles  and  tissues  until  they  are 
sufficiently  strong  to  maintain  the  normal  attitude.  Where  fixed  dis- 
tortion of  the  foot  is  present,  it  is  to  be  corrected  by  mechanical  or 
operative  measures. 

Supporting  Treatment. — Plates.  Indication  for  Support. — When 
the  strength  of  the  foot  is  inadequate  to  sustain  the  weight  of  the  body 
without  discomfort,  mechanical  support  is  needed.  Flat-foot  plates 
(Chapter  XXI.,  32)  are  indicated  in  such  cases  even  when  the  lower- 
ing of  the  arch  is  not  marked  to  the  eye,  but  when  the  symptoms  of 
strain  are  sufficiently  characteristic,  as  described  above.  Plates  are  not 
likely  to  be  of  use  in  rigid  and  deformed  flat-foot  where  it  is  not  possi- 
ble to  obtain  an  improvement  in  position  by  gentle  manipulation.  In 
such  cases  the  restoration  of  a  more  correct  position  should  precede  the 
use  of  plates. 

Casts  for  Plates. — For  the  construction  of  a  properly  fitting  plate  a 


FLAT-FOOT  AND    OTHER  DEFORMITIES.  581 

cast  of  the  foot  is  necessary.  This  is  made  from  a  plaster  mould  of  the 
foot  placed  in  as  near  a  correct  position  as  is  possible.  The  patient  is 
seated  and  the  foot  is  placed  in  a  pan  of  plaster  of  Paris  and  water  of 
about  the  consistence  of  melted  ice  cream.  No  weight  is  put  upon  the 
leg  during  this  proceeding,  and  the  plaster  is  heaped  up  around  the 
inner  side  of  the  ankle  and  is  allowed  to  harden.  The  foot  is  then  re- 
moved from  the  mould,  which  is  greased  with  vaseline  and  filled  with 
plaster-of-Paris  cream.  When  the  latter  hardens  it  is  removed  from  the 
mould  and  gives  a  representation  of  the  patient's  foot  in  a  somewhat 
corrected  position.  As  this  cast  furnishes  a  somewhat  sharp  contour 
of  the  sole  of  the  foot,  a  plate  shaped  exactly  to  it  would  be  likely  to 
present  rather  sharp  contours  and  not  be  so  comfortable  as  a  somewhat 
modified  shape.  It  is  therefore  necessary  for  the  surgeon  with  a 
sharp  knife  to  cut  away  something  of  the  lower  surface  of  the  cast  in 
order  to  insure  in  the  plate  an  even,  well-distributed  bearing  surface, 
pressing  most  on  the  points  where  pressure  is  desired.  It  must  be 
remembered  that  the  plate  should  furnish  support  to  the  hard  tissues 
of  the  foot  and  not  to  the  soft,  and  in  fat  feet  more  modification  will  be 
necessary  than  in  thin  ones.  It  is  also  necessary,  if  the  plate  is  to  be 
properly  balanced  and  set  evenly,  that  the  surgeon  should  cut  the  cast 
where  the  front  and  back  edges  of  the  plate  come,  in  such  a  way  that 
they  should  be  flat  and  approximately  in  the  same  plane ;  otherwise  a 
rocking  plate  or  one  with  uneven  edges  will  result. 

Another  method  of  preparing  casts  for  plates  is  to  model  them 
from  moulds  of  the  foot  made  in  dental  wax.  If  a  sheet  of  quickly 
hardening  dental  wax  is  softened  in  hot  water  and  placed  upon  the  bot- 
tom of  the  foot,  a  mould  can  be  taken.  When  it  is  hardened  it  can  be 
removed  from  the  foot,  and  can  be  cut  and  moulded  to  any  desired 
shape  by  immersion  again  in  hot  water.  In  this  way  a  wax  flat-foot 
plate  is  made  fitted  to  the  boot.  A  plaster-of-Paris  cast  can  be  taken 
of  this,  and  reproduces  exactly  the  shape  and  size  of  the  plate  desired. 
Manufachire  and  Material.— TYiQ.  best  all-round  material  for  the 
manufacture  of  plates  is  a  spring  tempered  steel  of  a  gauge  varying 
from  eighteen  to  twenty,  according  to  the  weight  of  the  patient.  For 
the  manufacture  of  plates  from  this  material,  the  services  of  an  instru- 
ment-maker or  of  a  skilful  blacksmith  are  necessary.  The  cast  should 
be  furnished  to  him  and  the  plate  forged  to  fit  the  cast  exactly.  It 
should  then  be  tried  on  the  patient,  before  or  after  which  it  should  be 
tempered.  For  final  use  the  plate  should  be  copper-plated  and  nickel- 
plated.  In  other  cases  it  is  more  convenient  to  cover  it  with  leather, 
but  the  moisture  of  the  foot  is  more  likely  to  rust  it  under  these  con- 
ditions than  when  it  is  nickel-plated.  Galvanizing  furnishes  a  perma- 
nent protection  against  rust,  but  the  process  destroys  or  impairs  the 
temper  of  the  plate.     A  galvanized  plate  should  therefore  be  made 


582  ORTHOPEDIC  SURGERY. 

heavier  than  others.  Of  other  material  used  for  the  manufacture  of 
plates  should  be  mentioned  phosphor  bronze,  which  is  malleable  and 
more  easily  fitted,  but  plates  made  from  it  are  much  heavier  than  of 
tempered  steel.  Sheet  celluloid  may  be  used  for  the  manufacture  of 
plates,  but  in  order  to  support  weight  it  has  to  be  very  thick,  and  even 
then  is  inclined  to  bend  or  break.  It  has  the  advantage  that  the  sur- 
geon can  make  and  shape  his  own  plates.  The  celluloid  is  cut  of  the 
desired  shape  and  is  bound  on  to  the  bottom  of  the  cast  by  rubber  tub- 
ing, which  is  wound  round  both  cast  and  plate  on  the  stretch ;  it  is  then 
immersed  in  boiling  water,  which  softens  it  until  it  takes  the  shape  of 
the  bottom  of  the  cast.     The  edges  should  be  smoothed  with  a  file. 

Another  efficient  but  somewhat  clumsy  use  of  celluloid  may  be  made 
by  the  surgeon.  A  celluloid  paste  is  made  by  dissolving  celluloid  chips 
in  acetone ;  this  is  then  painted  on  to  several  layers  of  gauze  laid  on  the 
cast,  between  which  strips  pieces  of  steel  wire  are  incorporated.  The 
wires  are  laid  on  in  different  directions,  giving  strength  as  desired. 
When  the  celluloid  has  hardened,  the  edges  of  the  plate  should  be 
trimmed. 

Shape  of  Plates. — Judgment  is  necessary  in  determining  the  proper 
shape  of  the  plate  in  each  case,  as  the  deformity  varies  both  in  degree 
and  in  kind.  The  shape  should  be  determined  by  the  part  of  the  foot 
which  needs  corrective  support.  In  the  milder  cases  all  that  is  needed 
is  to  furnish  support  to  the  sustentaculum  tali.  In  other  cases  the 
scaphoid,  cuneiform,  and  proximal  end  of  the  first  metatarsal  need  to 
be  raised.  In  some  cases  the  tendency  of  the  os  calcis  to  rotate  to  the 
inner  side  of  the  foot  is  to  be  checked,  and  in  other  cases  side  pressure 
is  needed  on  the  head  of  the  astragalus,  scaphoid,  and  cuneiform,  with 
counter-pressure  on  the  outer  side  of  the  foot.  The  most  practical 
way  of  determining  what  shape  of  plate  is  desirable  is  to  have  the 
patient  stand,  and  by  pressure  with  the  hand  to  see  in  what  place  the 
force  accomplishes  the  best  result.  In  general,  a  plate  should  be  higher 
along  the  inner  part  of  its  surface  than  on  the  outer,  but  it  should  not 
be  made  so  sloping  that  the  foot  continually  slides  off.  If  this  is  the 
case  a  counter-point  of  pressure  may  be  furnished  by  turning  up  the 
outer  flange  at  the  outer  edge  of  the  plate.  Ordinarily  it  is  advisable 
to  have  the  plate  support  nearly  the  whole  width  of  the  sole,  ending  in 
front  behind  the  sesamoid  bones  of  the  great  toe  and  at  the  back  end 
just  anterior  to  the  weight-bearing  surface  of  the  heel,  or,  if  desired, 
running  to  the  back  of  the  weight-bearing  surface  of  the  heel. 

If  the  anterior  part  of  the  foot  is  broken  down,  support  to  it  should 
be  furnished  by  raising  the  front  of  the  plate  in  a  dome-shaped  rise,  sup- 
porting the  part  of  the  foot  behind  the  heads  of  the  metatarsals.  In 
flexible  feet  a  shorter  plate  can  be  used  than  in  rigid  feet.  The  need 
of  an  inner  flange  and  its  height  will  be  determined  by  the  require- 


FLAT-FOOT  AND   OTHER  DEFORMITIES.  583 

ments  of  the  case;  the  same  is  t'-ue  of  the  outer  flange.  The  plate  at 
its  outer  border  should  not  project  beyond  the  outer  edge  of  the  shank 
of  the  boot,  or  it  will  push  out  the  leather  and  destroy  the  shape  of  the 
boot. 

Fitting  and  Use. — The  plate  should  be  shaped  in  such  a  way  as  to 
act  as  a  prop  to  the  portions  of  the  feet  which  drop  to  an  abnormal  po- 
sition when  weight  is  thrown  upon  them.  In  the  practical  fitting  of 
the  plate,  if  the  plate  is  rightly  shaped,  the  foot  when  not  bearing  weight 
should  lie  smoothly  against  the  bottom  of  the  plate,  not  springing  off 
at  the  front  or  back.  If  it  springs  off,  it  will  exert  more  pressure  than 
is  generally  comfortable.  When  the  plate  is  placed  in  the  boot  and  the 
patient  stands  upon  it,  there  should  be  a  sense  of  even,  well-distributed 
pressure,  and  not  a  feeling  as  if  the  patient  were  standing  on  a  ridge 
or  lump,  which  will  be  the  case  if  the  plate  is  too  high.  If  an  inner 
flange  is  used  it  should  not  press  too  much  upon  the  foot  when  weight 
is  borne  upon  it.  If  sensitive  points  in  the  foot  are  present  and  cause 
pain  when  weight  is  borne  upon  the  plate,  it  will  be  necessary  to  lower 
the  plate  opposite  these  points.  When  the  plate  is  first  applied  it 
should  be  worn  only  for  so  long  a  period  as  is  consistent  with  the  com- 
fort of  the  patient,  and  should  then  be  taken  out  to  rest  the  foot  if  nec- 
essary. If  the  plate  is  persistently  a  source  of  pain  it  will  not  give  the 
desired  relief,  but  will  cause  irritation  and  must  be  lowered  until  it  is 
comfortable.  No  point  is  more  commonly  neglected  than  this,  and  the 
very  common  use  by  patients  of  ill-fitting  supports  bought  at  shoe-stores 
brings  much  discredit  upon  the  use  of  plates.  The  plate  should  set 
firmly  in  the  shoe  and  should  not  rock,  and  the  front  and  back  ends 
should  be  in  contact  with  the  sole  of  the  boot. 

Misuse  of  Plates. — The  danger  of  injury  to  the  feet  by  the  too  con- 
stant use  of  plates  is  to  be  borne  in  mind.  The  plate  is  to  be  regarded 
in  the  same  light  as  is  a  crutch  or  cane  in  the  case  of  any  joint  unable 
to  bear  the  strain  of  use,  and  is  to  be  discarded  when  the  normal 
strength  has  returned  and  the  irritability  has  disappeared.  To  continue 
the  plate  after  the  indications  for  its  use  have  disappeared  is  to  hamper 
the  muscles  of  the  feet  and  to  prolong  the  unnatural  condition. 

Discontinuance  of  Plates. — When  the  symptoms  of  irritation  have 
disappeared,  a  trial  of  the  strength  of  the  foot  is  to  be  made  by  discon- 
tinuing the  plate  for  a  short  period  and  by  teaching  the  patient  to  hold 
the  foot  by  muscular  effort  in  the  corrected  position.  When  the  plate 
is  first  left  off,  prolonged  standing  and  walking  are  to  be  avoided,  and 
if  symptoms  of  irritation  follow  its  discontinuance  it  should  be  reap- 
plied. It  is  a  mistake  to  discontinue  the  plate  suddenly  or  for  the  pa- 
tient to  continue  to  go  without  it  if  symptoms  of  strain  are  present. 

Pads. — The  use  of  felt  or  leather  pads  supporting  the  arch  of  the 
foot  is  sometimes  of  use  temporarily  or  under  exceptional  conditions. 


584  ORTHOPEDIC  SURGERY. 

Such  pads  may  be  cut  of  the  desired  shape  and  worn  outside  the  stock- 
ing by  being  fastened  on  temporarily  by  a  tape  passing  round  the  foot 
or  by  being  incorporated  in  an  inner  sole  of  leather.  If  they  are  worn 
for  any  length  of  time  the  weight  of  the  foot  stretches  the  leather  of 
the  boot  and  breaks  down  the  shank  and  they  cease  to  be  of  value. 
Felt  or  leather  pads  are  frequently  of  use  in  persons  with  mild  flat-foot 
who  have  to  exercise  or  stand  in  gymnasium  shoes. 

TJie  Oblique  Sole. — Palliative  treatment  is  often  attempted  in  cases 
of  flat-foot  by  making  the  inner  side  of  the  sole  and  heel  of  the  boot 
one-eighth  or  one-fourth  of  an  inch  thicker  than  the  outside.  The 
weight  is  in  this  way  thrown  more  to  the  outer  side  of  the  foot  and  the 
strain  on  the  inner  side  is  somewhat  relieved.  The  thickness  of  the 
wedge  which  is  necessary  may  be  determined  experimentally  by  build- 
ing up  the  inner  side  of  the  boot  till  the  desired  position  is  obtained,  as 
determined  by  the  diminution  in  the  projection  of  the  internal  malle- 
olus. The  objection  to  the  method  is  that  the  foot  slides  on  the  incline 
of  the  sole  if  an  effective  elevation  in  the  sole  of  the  boot  has  been 
made  and  the  boot  is  distorted  by  the  stretching  of  the  leather  over  the 
outer  side;  in  addition  to  which,  the  pressure  of  the  outer  side  of  the 
foot  against  the  boot  is  uncomfortable. 

It  is  to  be  remembered  that  in  the  correction  of  flat-foot  not  only 
should  the  body  weight  fall  well  on  the  outer  ^(\gQ.  of  the  foot,  but  the 
great  toe  and  head  of  the  first  metatarsal  should  perform  their  normal 
functions  in  locomotion.  The  method  is  sometimes  useful  in  the  flat- 
foot  of  children  and  in  connection  with  the  use  of  plates;  in  the  latter 
case  a  slight  elevation  will  sometimes  diminish  the  strain  on  the  inner 
side  of  the  foot.  Of  itself,  however,  it  must  be  regarded  as  a  very  im- 
perfect method.  The  raising  of  the  inner  edge  of  the  heel  of  the  boot 
without  changing  the  sole  has  the  advantage  of  checking  somewhat  the 
inclination  of  the  os  calcis  to  roll  to  the  inside. 

M.\ssAGE,  Gymn.\stics,  ETC. — The  supportive  treatment  of  flat-foot 
should  be  reinforced  by  measures  to  stimulate  the  local  circulation  and 
to  strengthen  the  muscles  of  the  foot.  Massage  is  of  the  first  impor- 
tance, but  should  not  be  pushed  to  the  point  of  irritation.  The  use  of 
alternating  hot  and  cold  douches  or  of  a  local  hot  bath  followed  by  a 
cold  douche  is  of  much  value.  Vibratory  massage,  electricity,  and  the 
use  of  hot  air  may  be  of  use  in  especial  cases.  Exercises  to  increase 
the  power  of  the  deficient  muscles  are  sufificient,  in  connectioji  with  the 
measures  already  mentioned,  to  correct  many  of  the  milder  cases.  They 
form  an  important  part  of  the  treatment  of  all  cases,  mild  or  severe, 
whether  or  not  used  in  connection  with  support  to  the  arch,  and  are  to 
be  regarded  as  essential  to  treatment  of  any  form.  The  toeing-out 
habit  in  standing  and  walking  should  be  corrected.  Individuals  with 
strong  and  untrammelled  feet  stand  and  walk  with  but  little  diversfence 


FLAT-FOOT  AND   OTHER  DEFORMITIES. 


58; 


of  the  angle  of  the  feet.  The  greater  the  angle  of  divergence  in  walk- 
ing and  standing,  the  greater  the  tendency  to  strain  of  the  tissues  and 
to  falling  of  the  foot  to  the  inner  side. 

Shoes.- — Typical  flat-foot,  being  a  static  deformity,  is  in  general  to 
be  prevented  if  proper  precautions  are  taken.     Of  these  the  most  im- 


FlG.  533.— Showing-  Shoe  Constriction  of  Front  of  Foot,  with  Normal  Foot  in  Shoe  Before 
and  After  Removal  of  Upper. 

portant  is  footwear  which  does  not  distort  or  interfere  with  the  free 
movements  of  the  foot.  In  infants  beginning  to  walk,  in  whom  the 
body  weight  may  be  too  great  for  the  muscular  strength,  trouble  may 
be  averted  by  massage  and  manipulative  treatment,  the  avoidance  of 
great  fatigue,  and  the  use  of  proper  footwear.  In  older  children  with 
the  same  defect,  gymnastic  development  of  the  muscles  of  the  feet 
should  be  followed  out  and  faulty  shoes  avoided. 

The  adoption  of  proper  footwear  is  essential  not  only  to  protect  a 
foot  under  treatment  for  flat-foot  from  relapsing  to  its  deformity,  but 


586 


ORTHOPEDIC  SURGERl 


also  as  a  preventive  measure  in  young  children.     The  object  of  a  boot 
should  be  to  hold  the  foot  in  an  approximately  correct  position  and  not 


Pig.  534. — a,  Drawing  of  Normal  Position  of  Bones  of  Foot.  1^,  Fashionable  Shoe,  c,  Tracing 
of  Skiagram  of  Foot  in  Shoe,  Indicating  Cramping  and  Downward  Pressure  on  the  First 
Metatarsal. 

to  interfere  with  the  normal  function  of  the  foot  in  walking.     It  is  ob- 
vious that  the  great  toe  should  have  room  to  help  support  the  inner 


Fig.  535.— a,  Photograph  of  Humped  Foot,    d,  Tracmg  of  Skiagram  of  Humped  Foot  with 
Irritation  Exostosis  of  the  Metatarso-cuneiform  Articulation. 

border  of  the  foot ;  that  the  forefoot  should  not  be  cramped,  but  should 
have  room  to  be  placed  properly  on  the  ground,  in  order  to  perform  its 


FLAT-FOOT  AND    OTHER  DEFORMITIES. 


587 


weight-bearing  function ;  and  that  the  toes  should  be  given  room  and 
opportunity  to  touch  the  ground  in  their  proper  relation  and  thus  be  of 
use  in  walking,  and  that  the  outer  edge  of.  the  foot  should  have  an  op- 
portunity to  exert  its  normal  function  in  supporting  the  body  weight. 
These  requirements  necessitate  that  the  boot  or  shoe  should  have  a 
straight  inner  line,  that  the  shank  should  be  as  high  as  the  shank  of 
the  individual  foot  when  bearing  slight  weight.  This  should  not  be  too 
stiff,  permitting  the  normal  play  of  the  first  metatarsal  inward  and 


Fig.  536. — Tracing  of  Skiagram  of  Foot  in  Shoe  Before  and  After  Removal  of  Upper. 

downward,  and  should  be  slightly  higher  at  its  inner  than  its  outer  bor- 
der. The  forward  part  of  the  boot  should  be  as  wide  as  the  weight- 
bearing  foot  at  that  point,  and  the  toes  should  have  room  to  be  placed 
individually  on  the  ground.  The  forward  part  of  the  sole  should  not  be 
rolled  up,  but  should  be  flat,  to  enable  the  toes  to  finish  the  step  in 
walking;  neither  should  the  lower  surface  of  the  sole  be  convex  from 
side  to  side,  but  should  set  squarely  on  the  ground.  The  heel  should 
not  be  high.  The  forward  part  of  the  boot  should  be  at  somewhat  of 
an  angle  to  the  line  of  the  long  axis  of  the  heel,  that  is,  the  forefoot 
should  be  slightly  adducted  on  the  posterior  part  of  the  tarsus.  Since 
the  position  of  the  weakened  foot  is  one  of  abduction  of  the  forefoot, 
and  the  position  of  the  foot  under  muscular  support  is  one  of  adduction 
of  the  forefoot,  it  is  obvious  that  the  support  of  the  foot  in  the  former 


588 


ORTHOPEDIC  SURGERY. 


condition  is  corrective  in  character.  The  upper  should  not  be  shaped 
too  snugly  upon  the  dorsum  of  the  foot  or  be  so  inelastic  as  to  prevent 
the  flexible  action  of  the  toes. 

The  shape  of  the  shoe  has  become  conventionalized  to  such  an  ex- 
tent that  the  general  use,  among  the  leisure  class,  of  shoes  of  the  shape 
of  the  normal  foot  is  not  practicable.  The  people  of  the  city  streets 
will  not  be  shod  as  hunters.  It  is,  however,  practicable  to  limit  the  use 
of  fashionable  shoes  for  leisure  hours  and  working  boots  for  working 
hours.  The  boots  should  be  adapted  to  the  gait  and  use.  People  who 
use  the  front  of  the  feet  in  locomotion,  "front-foot"  walkers,  and  those 
walking  on  uneven  ground  need  more  room  in  the  front  of  their  boots 
than  heel  walkers  or  those  who  walk  on  an  everi  surface.     Individuals 


Fig.  537-— a  Shoe  Arranged  so  as  not  to  Cause  as  much  Pressure  on  the  Dorsum  and  Pre- 
venting the  l^istortion. 

with  any  tendency  to  flat-foot  should  have  walking  boots  as  well  as 
dress  boots,  and  the  feet  should  be  rested  as  much  as  possible  in  san- 
dals and  moccasins. 

The  Treatment  of  Painful  Cases.  — In  certain  cases  the  symp- 
toms of  local  irritability  reach  so  high  a  grade  that  especial  treatment 
is  needed.  Spasm  of  the  peroneal  muscles  may  be  present,  holding 
the  foot  in  an  abducted  position  and  resisting  movements  of  rectifica- 
tion. In  this  case  temporary  fixation  of  the  foot  in  a  plaster  bandage 
is  the  most  efficient  measure.  In  other  cases  great  irritability  is  caused 
by  a  tenosynovitis  from  joint  inflammation  incident  to  strain,  and  in 
these  cases  the  treatment  described  for  sprain  of  the  ankle  is  necessary. 
Irritated  flat-foot,  however,  is  not  so  favorably  affected  by  massage  as 
the  ordinary  sprain  of  the  ankle. 

Support  to  the  Leg  and  Foot.— In  the  severe  forms,  when  there 


FLAT-FOOT  AND    OTHER  DEFORMITIES.  589 

is  decided  eversion  of  the  foot,  a  support  holding  the  leg  is  needed. 
Such  may  be  afforded  by  means  of  a  steel  sole  plate,  with  an  upright 
passing  up  on  the  outside  of  the  leg,  with  a  supporting  strap  around  the 
inner  malleolus  described  in  speaking  of  infantile  paralysis,  or  as  a  sim- 
ple upright  attached  to  the  outer  side  of  the  sole  of  the  boot,  with  a 
leather  support  over  the  inner  malleolus  secured  to  the  upright  (Chap- 
ter XXI.,  31).  ^ 
Forcible  Correction.— In  cases  in  which  it  is  not  possible  to  place 
the  foot  in  an  approximately  correct  position  on  account  of  stiffness 
and   muscular   contraction,  it    is   generally  unsatisfactory  to  attempt 


Fig.  5-,8.-Deformity  Caused  by  the  Con.striction  and  Confinement  of  the  Foot. 

the  use  of  a  support  until  the  position  of  the  foot  has  been  corrected. 
Such  patients  should  be  anaesthetized  and  the  foot  forcibly  twisted  into 
shape.  It  must  be  remembered  that  there  are  two  elements  of  deform- 
ity to  be  corrected:  first,  eversion  of  the  foot;  and,  second,  abduction 
of  the  forefoot.  This  can  be  done  manually  in  many  cases,  but  in  severe 
cases  such  an  appliance  as  the  Thomas  club-foot  wrench  will  be  of  use 
in  giving  better  leverage,  or  the  foot  can  be  manipulated  over  a  padded 
wooden  wedge. 

The  foot  should  be  overcorrected  if  possible,  or  in  any  event  placed 
in  the  best  obtainable  position  and  held  by  a  plaster  bandage.  It  then 
follows  the  course  of  an  ordinary  sprained  ankle,  generally  of  slight  de- 
gree. As  soon  as  the  patient  can  walk  without  pain,  supports  should 
be  applied. 


590  ORTHOPEDIC  SURGERY. 

In  less  severe  cases  correction  can  be  gradually  accomplished  by 
the  repeated  application  of  plaster-of-Paris  bandages. 

In  extreme  cases  osteotomy  of  the  neck  of  the  os  calcis  and  astrag- 
alus may  be  needed. 

The  removal  of  a  wedge-shaped  piece  of  bone  from  the  inner  side  of 
the  midtarsus  has  been  recommended,  but  should  not  be  undertaken 
unless  it  is  certain  that  the  chief  obstacle  to  correction  lies  in  the  dis- 
torted shape  of  the  astragalus,  scaphoid,  and  os  calcis.  In  a  majority 
of  cases,  even  the  severe  ones,  forcible  correction  will  be  found  more 
efficient  than  wedge-shaped  exsection,  as  the  distortion  will  be  found  to 
be  distributed  in  various  parts  of  the  foot,  and  extensive  removal  of 
bone  will  be  followed  by  weakening  of  the  foot.     The  operative  details 


Fig.  539.— Forcible  Correction  of  Valgus  on  Wooden  Block.     (Berger  and  Banzet.) 

for  osteotomy  and  wedge  exsection  are  similar  to  those  to  be  regarded 
in  operating  on  club-foot,  it  being  remembered  that  the  deformity  is 
the  reverse  of  club-foot. 

The  most  notably  deficient  muscles  are  the  tibialis  posticus,  the 
tibialis  anticus,  the  flexor  longus  hallucis,  and  the  short  muscles  of  the 
sole  of  the  foot.     The  following  simple  exercises  will  be  found  useful : 

The  patient  walks  on  the  outer  edge  of  the  foot  with  the  inner  edge 
raised. 

The  patient  attempts  to  separate  the  great  toe  from  the  second 
toe  laterally  and  to  hold  it  in  that  position  while  walking. 

The  patient  flexes  the  toes  while  the  foot  is  free  and  grasps  objects 
in  them  by  their  plantar  surface. 

The  patient  walks  with  the  front  of  the  foot  directed  inward. 

The  patient  sits  with  the  leg  extended  and  resting  upon  the  assist- 
ant's knee.  Forcible  adduction  of  the  forefoot  is  then  made  while  the 
assistant  resists  lightly  with  one  hand  steadying  the  tibia  and  the  other 
pressing  against  the  ball  of  the  great  toe. 

The  patient  should  be  taught  to  rise  on  the  toes  at  the  end  of  each 
step,  finishing  the  step  with  the  toes. 


FLAT-FOOT  AND    OTHER  DEFORMITIES.  591 

The  patient  should  place  the  feet  together  in  a  parallel  position,  rise 
upon  the  toes  as  far  as  possible,  and  turn  the  heels,  and,  with  the  feet 
in  this  position,  lower  the  body  by  bending  the  knees. 

Such  exercises  as  the  surgeon  directs  should  be  performed  an  in- 
creasing number  of  times  each  day. 

Certain  other  painful  affections  and  acquired  deformities  of  the  feet 
are  sufficiently  allied  to  fiat-foot  to  be  considered  in  this  connection. 

METATARSALGIA. 

(Anterior  metatarsalgia,  Morton's  disease.) 

This  name  is  used  to  describe  a  cramping  pain  more  or  less  spas- 
modic, situated  between  the  distal  end  of  either  of  the  outer  three 
metatarsal  bones.  It  was  first  described  by  T.  G.  Morton,'  of  Phila- 
delphia, in  1876. 

Causation — The  pain  is  due  to  a  disturbance  in  the  normal  relation 
of  the  anterior  ends  of  the  metatarsal  bones,  causing  a  pinching  of  the 
external  plantar  nerve  between  the  ends  of  the  bones,  or  to  pressure  of 
the  metatarsals  on  other  digital  nerves,  or  to  abnormal  strain  upon  the 
ligaments  connecting  the  metatarsal  heads." 

The  affection  is  thus  due  to  the  disturbed  relation  in  the  position  of 
the  metatarsals  caused  by  faulty  footwear.  Normally  the  head  of  the 
first  metatarsal  bears  a  large  part  of  the  weight  which  comes  upon  the 
front  of  the  foot.  If  footwear  is  worn  which  gives  insufficient  room 
for  the  toes  and  at  the  same  time  exerts  a  crowding  pressure  upon  the 
metatarsals,  the  heads  of  the  first  and  fifth  metatarsals  are  unable  to 
drop  to  the  normal  plane  below  the  level  of  the  other  metatarsals,  owing 
to  the  narrowness  of  the  shoe.  The  weight  therefore  falls  unduly  on 
the  heads  of  the  other  metatarsals,  which  are  crowded  downward  as  the 
foot  slips  forward  in  the  boot. 

Symptoms. — The  condition  is  characterized  by  a  more  or  less  severe 
pain,  which  radiates  down  into  the  toes  and  often  up  into  the  leg.  The 
pain  usually  appears  when  the  patient  is  walking.  It  occurs  generally 
between  the  third  and  fourth  or  fourth  and  fifth  toes.  It  may  be  pre- 
ceded by  a  sensation  of  slipping  between  the  ends  of  the  metatarsals, 
or  the  slipping  may  occur  without  the  pain.  It  ordinarily  comes  on 
when  the  boots  are  on,  but  may  sometimes  be  occasioned  by  rising  on 
the  toes  in  the  stocking  feet.  The  patient  seeks  relief  instinctively  by 
removing  the  boot  and  manipulating  the  foot,  which  relieves  the  acute 
pain.  Some  soreness  may  remain  afterward  and  a  tender  spot  is  often 
found  at  the  seat  of  the  pain. 

The  attacks  of  pain  may  become  gradually  more  frequent  and  more 

'  Amer.  Journ.  Med.  Sciences,  1S76. 

-Jones:  Liverpool  Med -Chir.  Journ.,  January,  1S97. 


592  ORTHOPEDIC  SURGERY. 

severe  until  a  condition  of  disability  is  established,  the  patient  dreading 
walking.     Spontaneous  recovery  may  occur,  but  is  uncommon. 

The  foot  may  be  normal,  so  far  as  can  be  ascertained  on  inspection. 
Oftener,  however,  one  or  more  of  the  following  variations  from  the 
normal  may  be  detected. 

1 .  The  foot  may  be  weakened  and  the  standing  position  show  slight 
dropping  of  the  arch. 

2.  The  anterior  arch  of  the  foot,  or  the  arch  normally  formed  by 
the  heads  of  the  metatarsal  bones,  if  looked  at  in  a  cross  section  of  the 
foot,  is  relaxed  and  flattened.  The  heads  of  the  second,  third,  and 
fourth  metatarsals  are  on  a  lower  level  than  normal. 

3.  Dorsal  flexion  of  the  foot  may  be  limited  on  manipulation. 
Callosities  may  be  found  under  the  heads  of  the  metatarsals,  and 

one  or  more  of  the  metatarsal  heads  may  be  felt  unduly  prominent  in 
the  sole  of  the  foot. 

Motion  of  the  toes,  especially  in  severe  cases,  is  apt  to  be  limited  in 
the  direction  of  plantar  flexion. 

Diagnosis.  —This  affection  is  frequently  diagnosticated  as  neuralgia, 
for  which  only  general  treatment  is  prescribed,  yet  the  diagnostic 
symptoms  are  perfectly  well  marked  and  definite  and  not  like  those  of 
any  other  affection. 

The  prognosis  without  treatment  is  not  good;  the  attacks  as  a  rule 
become  more  frequent  and  painful,  though  spontaneous  recovery  does 
rarely  occur.  With  proper  mechanical  treatment  most  patients  recover, 
but  occasionally  very  obstinate  cases  are  seen  which  resist  all  the  ordi- 
nary methods  of  treatment. 

Treatment. — It  is  obviou-:  that  if  any  static  deformity  of  the  foot 
exists  it  should  be  corrected.  If  the  weakened  foot  is  present  a  proper 
plate  should  be  applied,  brought  well  forward  with  an  elevation  behind 
the  distal  ends  of  the  metatarsals.  If  the  anterior  arch  is  relaxed  and 
flattened,  a  felt  or  metal  pad  should  be  placed  under  it  behind  the  heads 
of  the  metatarsals.  In  short,  measures  should  be  adopted  to  relieve 
the  front  ends  of  the  metatarsals  from  pressing  down  on  to  the  sole  of 
the  foot  in  finishing  the  step  \\\  walking. 

Proper  boots  with  a  broad  sole  should  be  worn,  and  compression  of 
the  front  of  the  foot  by  boots  should  be  avoided.  The  normal  flexibility 
of  the  toes  should  be  cultivated  by  proper  exercises.  In  some  cases, 
however,  compression  of  the  shafts  of  the  metatarsals  for  a  time  affords 
relief.  In  these  cases  it  can  be  afforded  by  adhesive  plaster,  by  band- 
aging, or  by  a  boot  made  tight  over  the  shafts  of  the  metatarsals.  Re- 
moval of  the  distal  end  of  the  fourth  metatarsal  has  been  advo- 
cated as  a  measure  of  treatment,  but  it  is  not  often  necessary  to  resort 
to  this. 


FLAT-FOOT  AND   OTHER  DEFORMITIES. 


593 


HALLUX  VALGUS. 

This  name  is  applied  to  the  outward  displacement  of  the  great  toe. 
In  the  normal  foot,  as  seen  in  children  and  people  who  do  not  wear 
boots,  the  long  axis  of  the  great  toe  vyhen  prolonged  backward  passes 
through  the  centre  of  the  heel  (Meyer's  line). 

Causation.— This  deformity  of  the  great  toe,  however,  is  not  neces- 
sarily the  result  of  tight  shoes,  for  the  deformity  may  come  in  people 
who  have  worn  only  comparatively  loose  ones.     The  upper  leather  of 

shoes,  being  more  yielding  than  the 
sole,  stretches  under  the  pressure 
of  use,  or  is  stretched  to  avoid 
pressure  upon  the  metatarso-pha- 
langeal  articulation.  The  boot  is 
not  stretched  at  its  extreme  end 


Fig.  540.— Hallux  Valg-us.    Great  toe  unde 


FIG. 


541. -Hallux  Valg-us.     Great  toe  over. 


and  it  inevitably  becomes,  in  a  degree,  conical  in  shape  on  this  account, 
being  broader  across  the  ball  of  the  foot  than  at  the  tip  end.  In  the  act 
of  walking  the  foot  necessarily  slips  inside  of  the  boot  to  a  certain  extent, 
and  if  the  shoe  slips  backward  and  the  foot  forward,  a  certain  amount  of 
pressure  will  come  upon  the  inner  side  of  the  end  of  the  great  toe, 
tending  to  displace  it  outward. 

This  deformity  may  also  be  occasioned  by  short  boots,  and  the  ordi- 
nary pointed-toe  boots,  or  any  boot  which  does  not  give  more  room  for 
lateral  spreading  at  the  toes  than  at  the  metatarso-phalangeal  articula- 
tion, would  necessarily  give  rise  to  the  trouble.  Stockings  are  also  a 
factor  in  its  production. 


594 


ORTHOPEDIC  SURGERY. 


Symptoms. — When  the  deformity  continues  for  any  length  of  time, 
alteration  in  the  relation  of  the  bones  of  the  metatarso-phalangeal  joint 
takes  place.  The  head  of  the  metatarsal  is  partly  uncovered  as  the 
phalanx  is  pushed  to  the  outer  side,  and  the  head  of  the  metatarsal  may 
become  enlarged  from  growth  of  the  bone  due  to  periosteal  irritation. 
The  skin  over  this  prominent  joint  may  grow  thick  and  a  bursa  form 
over  it.    This  may  become  inflamed,  giving  rise  to  an  extensive  cellulitis, 


Fig. 


\';,';;<us,  Crowded  Litile  Toes,  and  Weakened  Toes 


which  may  include  the  whole  dorsum  of  the  foot,  which  may  suppurate 
and  cause  necrosis  of  the  bone.  This  latter  termination  is,  however,  rare 
and  occurs  only  in  neglected  cases.  The  inflammation  of  this  bursa  is 
known  as  a  bunion. 

The  symptoms  due  to  hallux  valgus  in  the  non-inflammator}'  stages 
are  chiefly  those  resulting  from  the  alteration  of  the  shape  of  the  foot. 
In  aggravated  cases  a  peculiar  gait  is  noticeable,  the  foot  is  thrown 
out,  and  there  is  loss  of  elasticity  in  the  gait.  There  may  be  pain  and 
irritability  in  the  great  toe-joint,  and  in  severe  cases  extreme  pain  and 
difficulty  in  walking,  which  is  usually  attributed  by  the  patient  to  gout. 


1-LAT-FOOr  AND    OTHER  DEFORMITIES. 


595 


On  examination,  sensitiveness  of  the  metatarso-phalangeal  joint  is  de- 
tected on  pressure.  In  its  more  marked  degree  it  is  almost  exclusively 
an  affection  of  adult  life,  but  is  occasionally  seen  in  adolescence.  In  a 
slight  degree  it  is  almost  universally  present  after  middle  childhood. 


Fig.  543. — X-xiij  of  Hallux  Valgus,  Showlnfj  how  the  Shoe  Causes  a  Deformity, 

Treatment. — The  treatment  of  hallux  valgus  in  early  cases  may  be 
carried  out  by  wearing  a  splint  of  steel  or  hard  rubber  along  the  inner 
border  of  the  foot  fastened  behmd  to  the  metatarsus.  To  the  front  end 
of  this  splint  the  toe  is  bandaged  or  strapped  and  thus  pulled  outward. 

The  use  of  a  toe  post  is  sometimes  beneficial.     That  is,  a  metal 

partition  is  attached  to  or  passed  up  through  the  sole  of  the  boot,  which 

shall  come  between  the  first  and  second  toes  and  hold  the  great  toe  in 

an  improved  position.^     For  the  use  of  this  toe  post  a  stocking  is  re- 

'  Sampson  :  Johns  Hopkins  Bulletin,  January,  1902. 


50  ORTHOPEDIC  SURGERY. 

quired  which  shall  have  a  division  between  the  great  toe  and  the  other 
toes  (Chapter  XXI.,  33).  The  use  of  a  foot-plate  curved  to  support 
the  arch  of  the  foot  will  be  of  use  when  the  foot  is  weakened  or  fiat. 

Shoes  should  be  so  constructed  that  no  pressure  is  possible  which 
will  force  the  great  toe  to  the  outer  side.  The  sole  of  the  shoe  should 
be  not  only  as  broad  as  the  sole  of  the  foot,  but  in  cases  in  which  there 
is  a  tendency  to  this  deformity,  room  should  be  made  in  the  front  of 
the  shoe  for  the  first  metatarso-phalangeal  joint. 

Operation. — In  old  cases  attempts  to  correct  the  deformity  by  such 
means  as  those  mentioned  are  generally  unsuccessful  and  operative 


Fig.  544. — Hallux  Valgus  or  Out-toe. 

measures  may  be  adopted.  The  joint  may  be  resected  through  an  in- 
cision along  the  inner  and  upper  surface  of  the  joint. 

The  ends  of  the  bones  composing  the  joint  are  then  exposed  and 
dissected  freely  enough  to  be  pushed  out  of  the  wound  one  at  a  time. 
The  articular  surfaces  are  sawed  through  or  cut  off  with  heavy  bone 
forceps  in  such  planes  that  when  the  cut  ends  are  in  apposition  the  toe 
will  lie  in  the  desired  straight  line.  The  wound  is  then  closed  and  a 
plaster-of-Paris  bandage  applied  over  the  antiseptic  dressing,  which 
must  be  applied  with  much  care  of  the  position  of  the  toe.  Wiring  of 
the  bones  is  not  necessary. 

The  use  of  properly  made  shoes  is  essential  for  after-treatment,  and 
also  for  the  prevention  of  the  increase  or  recurrence*  of  the  deformity. 


FLAT-FOOT  AND    OTHFR  DEFORMITIES.  S97 

HALLUX   VARUS. 

This  deformity  is  not  a  common  one,  and  is  known  also  as  in-toe  or 
pigeon-toe.  .  It  is  rarely  of  any  importance,  and  although  often  con- 
genital in  origin,  it  may  occasionally  be  seen  in  young  children  with 
flat-foot,  and  the  writers  have  observed  it  in  a  few  cases  of  overcor- 
rected  club-foot  in  which  a  valgus  has  resulted.  It  is  also  seen  in  con- 
nection with  severe  knock-knee  at  times. 

This  distortion  does  not  generally  require  treatment,  and  the  use  of 
ordinary  shoes  is  sufficient  to  correct  the  deformity. 

HALLUX    RIGIDUS. 

This  deformity  is  sometimes  seen  in  adolescents,  and  is  a  stiffness 
of  the  metatarso-phalangeal  joint  of  the  great  toe.  The  deformity  may 
may  be  a  flexion  of  the  proximal  phalanx  of  the  great  toe  through  30° 
to  60°,  with  extension  of  the  second  phalanx,  or  the  joint  may  be  rigid 
in  the  straight  position. 

The  symptoms  vary  with  the  stage  of  the  disease.  Early  there  may 
be  slight  pain  over  the  joint  and  painful  motion,  but  the  cases  rarely 
come  to  the  surgeon's  notice  at  this  time.  Later  there  is  swelling  over 
the  joint,  with  tenderness,  and  perhaps  an  enlargement  of  the  bone 
itself.     The  usual  atrophy  after  ankylosis  often  occurs  here. 

The  condition  is  often  associated  wdth  flat-foot.  Ill-fitting  shoes  also 
have  an  influence  in  causing  the  distortion.  At  times  it  arises  from  an 
injury. 

The  treatment  in  the  early  stages  will  consist  in  removing  the  excit- 
ing cause  and  properly  supporting  the  foot.  If  there  is  pain,  with  signs 
of  inflammation,  rest  with  local  applications  is  indicated,  and  later  pro- 
tection by  splints  with  support  of  the  arch  of  the  foot.  In  inveterate 
cases  excision  of  the  joint  may  be  necessary.  • 

HAMMER   TOE. 

This  deformity  consists  of  a  claw-like  contraction  of  one  of  the  toes, 
usually  the  second  or  third.  The  condition  is  one  of  flexion  of  the 
second  phalanx,  with  extension  of  the  third,  so  that  the  pressure  on  the 
ground  is  sustained  by  the  distal  phalanx.  Over  the  upward  projecting 
joint  there  is  usually  a  callosity,  which  may  cause  considerable  annoy- 
ance. ,  ' 

The  origin  of  the  deformity  is  not  w^ell  understood,  but  in  some 
cases  it  is  apparently  caused  by  short  boots. 

In  the  slight  degrees  and  early  stages  of  the  deformity  the  patient 
experiences  but  little  discomfort,  and  such  cases  are  not,  therefore, 


598 


OR  THOPEDIC  S  UR  GER  V. 


Later,  however,  locomo- 


commonly  seen  by  the  surgeon  in  this  stage. 
tion  becomes  difficult  and  painful. 

In  children  and  adolescents  the  deformity  can  generally  in  all  but 
the  severest  cases  be  corrected  by  simple  mechanical  treatment.  The 
toe  should  be  bandaged  or  strapped  to  a  rigid  plantar  splint,  which  can 
easily  be  made  of  tin.  The  strapping  should  be  renewed  often  enough 
to  keep  the  toe  extended.  In  children  it  can  be  corrected  if  necessar\- 
by  subcutaneous  section  of  the  contracted  fasciae,  forcible  straightening, 


Fig? 545. — Drawing'  r.p  of  ihe  Toes,  Caused  by  Pressure  of  the  Shoe  on  the  Dorsum  of  the  Foot. 

and  fixation  in  a  straight  position  b)'  means  of  splints  and  adhesive 
plaster. 

After  correction  by  mechanical  means  the  toe  shows  a  tendency  to 
recontract  and  must  be  carefully  watched. 

Amputation  at  the  interphalangeal  joint  is  of  no  use,  as  the  proximal 
phalanx  remains  still  elevated. 

In  severe  cases  it  is  possible  to  excise  the  prominent  phalangeal 
joint  of  the  toe  which  projects  upward,  and,  by  taking  out  sufficient 
bone  from  the  phalanges,  to  bring  two  bony  surfaces  together,  which 
will  unite  and  keep  the  toe  straight  and  flat. 

To  amputate  the  second  toe  when  it  is  affected  will  cure  the  de- 
formity, but  is  objectionable  because  it  leaves  a  space  between  the 
great  and  third  toes,  into  which  the  great  toe  is  likely  to  be  crowded 
over,  resulting  in  a  severe  type  of  hallux  valgus. 


FLEXED    OR    "CLAWED"    TOES. 

A  contracted  position  of  several  toes  is  sometimes  seen,  either  as  a 
result  of  improper  shoeing  or  as  a  sequel  to  a  previous  paralysis  of 
some  of  the  muscles  of  the  foot.     It  also  occurs  at  times  in  connection 


FLAT-FOOT  AND    OTHER  DEFORMITIES.  599 

with  what  is  spoken  of  as  contracted  foot.  The  tendons  and  fascia? 
will  be  found  shortened. 

This  deformity  is  to  be  treated  in  the  same  way  as  the  contraction 
of  one  toe.  In  this,  as  in  all  similar  affections  of  the  toes,  properly 
made  shoes  are  necessary  to  prevent  relapse  or  to  secure  permanent 
recovery. 

In  obstinate  cases,  all  contracted  fasciae  or  tendons  should  be  freely 
divided  and  the  toes  retained  in  a  corrected  position. 

PAINFUL    HEEL. 

A  tender  and  painful  area  under  the  middle  of  the  heel  exists  at 
times,  and  is  spoken  of  sometimes  as  "policeman's  heel."  It  seems  to 
be  associated  with  any  one  of  three  conditions : 

1.  The  radiograph  may  show  a  bony  spur  projecting  forward  from 
the  front  lower  edge  of  the  tuberosity  of  the  os  calcis.  This  may  or 
may  not  be  associated  with  exostoses  elsewhere  in  the  tarsal  bones. 

2.  It  may  be  associated  with  inflammation  of  the  bursa  under  the  os 
calcis. 

3.  It  may  be  the  expression  of  a  static  disturbance  (some  degree  of 
flat-foot),  in  which  the  chief  strain  falls  on  the  posterior  insertion  of 
the  plantar  fascia. 

The  treatment  consists  in  the  application  of  a  foot-plate  depressed 
under  the  painful  area. 

POST-CALCANEAL    BURSITIS. 

(Achillodynia,  Achillobursitis,  Anterior  Achillobursitis.)' 

A  tender  swelling  at  the  junction  of  the  tendo  Achillis  and  os  calcis 
is  not  infrequently  met.  Plantar  flexion  of  the  foot  is  painful,  and  the 
patient  walks  with  the  foot  everted  and  avoids  rising  on  the  toes.  The 
affection  may  be  unilateral  or  bilateral,  and  is  rather  resistant  to  treat- 
ment" and  liable  to  recur  when  nearly  well. 

It  generally  follows  a  long  walk,  prolonged  skating,  or  a  sudden 
misstep  throwing  the  weight  on  the  toe.  At  other  times  it  seems  to  be 
caused  by  the  pressure  of  the  leather  at  the  back  of  the  boot  binding 
the  tendo  Achillis. 

For  the  milder  cases  restricted  and  everted  use  of  the  foot,  douches, 
and  the  use  of  a  cane  will  be  sufficient  to  effect  a  cure,  but  the  im- 
provement is  slow.  It  is  often  necessary  to  remove  pressure  over  the 
painful  area  by  splitting  the  heel  of  the  boot  in  the  middle  line  behind 
and  setting  in  a  loose  piece  of  leather  between  the  spread  edges. 

'Albert:  Wiener  med.  Presse,  January  Sth.  1S93. 
-Rossler:  Deut.  Zeit.  f.  Chir.,  Ixii.,  i  and  3. 


6oo  ORTHOPEDIC  SURGERY. 

In  resistant  and  very  acute  cases  the  application  of  a  plaster-of- 
Paris  bandage  to  the  leg  and  foot  will  be  necessary. 

An  inflammation  of  a  superficial  bursa  between  the  tendon  and  the 
skin  occasionally  occurs  from  pressure  of  the  boot  heel.  Its  treatment 
obviously  consists  in  the  removal  of  the  pressure. 

SYNOVITIS    OF    THE    TENDO    ACHILLIS. 

Symptoms  somewhat  like  those  described  occur  at  times  in  connec- 
tion with  a  tenosynovitis  of  the  tendo  Achillis,  which  is  shown  by  the 
usual  signs  of  swelling  of  the  sheath  of  the  tendon  above  the  os  calcis, 
tenderness  along  its  course,  and  silky  crepitus.  The  affection  is  readily 
controlled  by  the  milder  class  of  measures  mentioned  above. 

EXOSTOSES  OF  THE  TARSAL  BONES, 

especially  of  the  os  calcis,  are  found  from  time  to  time  accompan}-ing 
a  painful  and  even  a  disabling  condition  of  the  foot.  Inflammation  of 
the  post-calcaneal  bursa  has  been  described  in  connection  with  this 
condition.'     The  exostoses  are  found  by  skiagraphs. 

The  etiology  is  obscure.  The  affection  is  obstinate  and  recovery 
slow.  It  is  not,  as  a  rule,  much  benefited  by  treatment,  and  the  re- 
moval of  the  exostoses  has  not  regularly  been  followed  by  relief  and 
should  not  be  undertaken  in  the  very  acute  stage. 

Rest,  dry  heat,  fomentations,  douching,  massage,  etc.,  all  have  their 
place  in  improving  certain  cases.  Partial  relief  is  often  to  be  obtained 
by  the  use  of  a  support  to  the  arch  of  the  foot,  relieving  the  heel  from 
some  of  its  pressure. 

'Painter:  Orth.  Trans.,  vol.  xi.  (with  bibliography). 


CHAPTER    XXI. 
PRACTICAL    DETAILS   OF    APPARATUS. 

I.  Plaster-of-Paris  bandages.— 2.  Celluloid  bandages.— 3.  Leather  splints  and 
jackets.— 4.  Antero-posterior  support  for  Pott's  disease. — 5.  Oval  ring  head 
support.— 6.  Anterior  head  support.— 7.  Thomas  collar.— 8.  Quadrilateral 
back  brace.— 9.  The  gas-pipe  bed  frame.  — 10.  Traction  hip  splint.— 11.  Con- 
valescent hip  splint. — 12.  The  double  upright  hip  splint.  — 13.  Thomas  hip 
splint.  — 14.  Thomas  knee  splint.— 15.  Thomas  caliper  splint. — 16.  Jointed 
knee  splint.  — 17.  Fixation  ankle  splint.— 18.  Knock-knee  brace.  — 19.  Bow-leg 
brace. — 20.  Anterior  bow-leg  brace.— 21.  Antero-posterior  bow-leg  brace.— 
22.  Tempered  steel  uprights.— 23.  Brace  with  movable  shoulder-pieces.— 24. 
Torticollis  brace.— 25.  Caliper  apparatus  for  anterior  poliomyelitis.— 26.  Sup- 
porting leg  brace  for  anterior  poliomyelitis.— 27.  Equino-varus  splint. — 28. 
Apparatus  for  talipes  equinus.— 29.  Apparatus  for  talipes  calcaneus. — 30. 
Apparatus  for  talipes  varus.— 31.  Apparatus  for  talipes  valgus.— 32.  Flat-foot 
plates. — 33.  Toe  post. 

It  is  obviously  desirable  that  surgeons  undertaking  the  treatment 
of  orthopedic  cases  should  not  be  wholly  dependent  upon  instrument- 
makers.  Not  only  is  it  important  that  the  surgeon  should  be  able  to 
fit  and  adjust  his  own  apparatus,  for  except  in  the  larger  cities  instru- 
ment-makers are  not  available.  The  following  details  are  given  in  the 
hope  of  enabling  surgeons  to  undertake  the  measurement  and  con- 
struction of  the  simple  forms  of  the  common  apparatus.  In  most  cases 
the  construction  of  the  apparatus  below  is  within  the  reach  of  a  black- 
smith of  ordinary  skill,  and,  with  the  assistance  of  a  harness-maker  to 
do  the  leather  work,  the  construction  of  the  apparatus  described  should 
not  present  any  intrinsic  difficulty.  The  forms  of  apparatus  described 
are  those  which  for  many  years  have  been  in  satisfactory  use  at  the 
Children's  Hospital,  Boston.  It  need  hardly  be  said  that  nicety  of 
finish  and  elegance  of  construction  do  not  add  to  the  efficiency  of  the 
apparatus,  however  desirable  these  qualities  may  be  in  making  appara- 
tus for  persons  who  are  able  to  bear  the  extra  expense.  In  order  to 
secure  uniformity  the  apparatus  described  is  adapted  for  the  use  of  a 
child  ten  years  old,  and  for  patients  much  older  or  much  younger  allow- 
ances must  be  made  in  the  strength  and  weight  of  the  apparatus. 

I.    PLASTER-OF-PARIS    BANDAGES. 

Plaster  bandages  are  of  two  types,  the  quick  setting  and  the  slow- 
setting.     The  quick  setting  are  to  be  used  when  rapidity  of  application 

601 


602  ORTHOPEDIC  SURGERY. 

is  desirable,  as  in  the  case  of  young  children,  in  the  application  of  plas- 
ter jackets  in  suspension,  and  in  all  conditions  where  for  any  reason  it 
is  desirable  to  save  tmie.  Splints  made  with  quick-setting  bandages 
are  more  liable  to  break,  and  are  not  so  durable  as  bandages  which  take 
more  time  in  setting.  The  setting  of  plaster  bandages  is  hastened  by 
the  addition  of  salt  or  alum  to  the  water  in  which  they  are  soaked, 
about  a  tablespoonful  to  a  pail  of  water.  It  is  also  influenced  some- 
what by  the  kind  of  plaster  and  gauze  used.  The  setting  of  plaster  is 
delayed  by  the  presence  of  glue  either  in  the  sizing  of  the  material  used 
or  added  to  the  water  if  desired. 

Material. — The  best  material  to  be  used  for  plaster  bandages  is 
white  crinoline,  40  by  40,  not  sized  or  starched. 

If  crinoline  sized  with  glue  is  the  only  kind  obtainable,  it  should  be 
washed  and  dried,  to  remove  the  glue,  and  then  cut  and  rolled  into 
bandages.  As  it  wrinkles  in  drying  it  is  more  difficult  to  cut  and  to 
handle  under  these  conditions.  Crinoline  sized  with  glue  sets  very 
slowly  and  is  objectionable  on  that  account.  Crinoline  sized  with 
starch  costs  from  six  to  nine  cents  a  yard.  Bandages  may  be  also  made 
of  coarse  cheesecloth,  but  it  is  more  difficult  to  cut  than  the  stiffer 
crinoline  and  on  the  whole  is  less  satisfactory,  but  it  is  cheaper,  cost- 
ing from  about  three  cents  a  yard  upward.  As  the  best  bandage  is  one 
that  will  hold  plaster  in  its  meshes  and  not  simply  smeared  on  its  sur- 
face, the  material  used  should  have  a  coarse  mesh.  The  best  plaster 
splint  is  not  one  of  alternate  layers  of  cloth  and  plaster,  but  one 
in  which  the  layers  of  cloth  are  cemented  together  by  plaster  of 
Paris. 

Size  of  Bandages. — For  use  in  the  application  of  bandages  for  the 
legs  and  for  plaster  jackets,  the  width  of  the  bandages  should  be  from 
three  to  four  inches  and  the  length  four  yards.  The  weight  of  a 
bandage  four  inches  wide  and  four  yards  long  should  be  approximately 
from  five  to  six  ounces,  including  the  plaster  rubbed  in.  For  the  cor- 
rection of  club-foot  in  young  children,  the  width  of  the  bandages  should 
be  two  inches  and  the  length  not  over  two  or  three  yards. 

Plaster. — High-grade,  finely  pulverized  plaster,  sometimes  called 
"dental,"  is  the  quickest  and  best  for  general  use.  Ordinary  plaster  of 
the  highest  grade  sets  somewhat  more  slowly.  The  plaster  should  be 
kept  in  a  dry  place  and  preferably  should  be  fresh,  and  if  at  all  old  or 
damp  the  bandages  should  be  dried  in  an  oven  before  using.  Powdered 
dextrin  may  be  added  to  the  plaster  before  winding  the  bandages,  in 
the  proportion  of  about  one  to  ten,  but  it  delays  the  setting,  although 
it  makes  the  bandage  more  durable.  Five  per  cent  of  Portland  cement 
added  to  the  plaster  before  rolling  quickens  the  setting  and  hardens  the 
bandage,  but  discolors  it  somewhat.  For  general  use  plaster  of  Paris 
is  the  best  material. 


PRACTICAL  DETAILS   OF  APPARATUS.  603 

Rolling  of  Bandages. — Although  many  forms  of  machines  for  roll- 
ing plaster  bandages  have  been  described,  most  surgeons  find  it  more 
convenient  to  have  them  rolled  by  hand.  The  gauze  or  crinoline  band- 
age is  laid  flat  on  the  table  and  a  heap  of  plaster  is  placed  on  the  table 
near  it.  A  handful  of  the  plaster  is  then  laid  on  the  bandage,  and,  with 
a  flat  piece  of  splint  wood  or  a  case  knife,  this  handful  of  plaster  is 
pushed  along  over  the  bandage  and  any  excess  of  plaster  thus  removed. 
The  end  of  the  bandage  impregnated  with  plaster  is  then  rolled,  the 
bandage  pulled  along,  and  another  handful  of  plaster  placed  upon  it  and 
the  bandage  impregnated  in  the  way  described  above. 

Bandages  should  be  rolled  loosely ;  if  they  are  rolled  tightly  the 
water  will  not  saturate  the  centre  of  the  bandage. 

Soaking  the  Bandage. — The  bandages  should  be  soaked  in  a  pail 
containing  at  least  six  inches  of  water,  sufficiently  warm  not  to  chill  the 
patient.  The  bandages  are  put  in  the  pail  resting  on  their  ends,  and 
are  allowed  to  remain  until  bubbles  have  ceased  to  come  to  the  surface 
of  the  water.  They  are  then  squeezed  by  holding  them  with  the  hand 
over  each  end  to  prevent  the  escape  of  the  plaster  until  they  are  suffi- 
ciently dry  not  to  drip.  If  they  are  taken  out  too  soon  the  plaster  is 
not  sufficiently  softened,  and  if  they  are  left  too  long  they  will  set  in 
the  water. 

Protection  of  Patient's  Skin. — ^When  it  is  desirable  to  put  on  a 
bandage  which  will  not  be  too  bulky  and  when  there  is  no  reason  to 
suppose  that  swelling  will  occur  after  the  application,  the  skin  may  be 
protected  by  a  stocking,  by  one  or  two  layers  of  a  gauze  bandage 
smoothly  laid  on,  or  by  a  layer  of  stockinet,  over  which  the  plaster  is 
smoothly  applied.  When  there  is  reason  to  suppose  that  there  may  be 
swelling,  when  the  patient  lives  at  a  distance,  or  when  the  bony  promi- 
nences are  very  marked,  it  will  be  desirable  to  protect  the  skin  and  to 
guard  against  harmful  pressure  by  the  application  of  layers  of  sheet 
wadding  smoothly  applied  in  sufficient  thickness  to  guard  against  press- 
ure. This  is  especially  the  case  in  the  application  of  bandages  after 
osteoclasis  and  in  the  correction  of  club-foot.  In  the  application  of 
jackets  the  skin  should  be  protected  by  putting  on,  first,  a  thin  sleeve- 
less undervest  without  buttOQS,  known  as  "  women's  ribbed  undervests," 
costing  about  three  cents  a  piece  when  bought  by  the  dozen ;  or  a  layer 
of  stockinet  is  placed  on  the  trunk  and  cut  off  at  the  desired  length. 
Stockinet  is  sold  in  tubes  of  various  sizes  and  the  required  piece  can 
be  cut  off  of  the  desired  length.  Bony  prominences  should  be  padded 
by  felt  pads.  The  felt  may  be  obtained  in  varying  thicknesses  from 
one-quarter  to  three-quarters  of  an  inch,  and  varies  in  quality  from  what 
is  known  as  saddle  felting  to  piano  felting,  which  is  the  best  grade. 
The  felt  should  not  be  put  next  to  the  skin,  but  put  outside  of  whatever 
is  used  to  protect  the  skin  from  the  plaster.     In  the  application  of  plas- 


6o4  ORTHOPEDIC  SURGERY. 

ter  jackets  it  is  not  necessary  or  desirable  to  wind  the  body  in  sheet 
wadding. 

Application  of  Bandages. — Bandages  should  be  applied  with  a  smooth, 
even  pressure  and  uniform  tension  throughout  each  turn.  They  should 
not  be  put  on  with  too  much  tension,  reverse  turns  should  never  be 
made,  and  there  should  be  no  correction  in  the  position  of  the  joint  or 
limb  after  the  plaster  has  begun  to  set ;  otherwise  folds  will  be  made  in 
the  inside  of  the  bandage,  which  may  cause  sloughs  or  impair  circula- 
tion. Every  portion  of  each  turn  should  be  thoroughly  rubbed  with 
the  hand  to  unite  the  layers,  and  nothing  in  the  application  of  a  proper 
kind  of  bandage  contributes  so  much  to  the  stability  and  strength  of 
a  splint  or  jacket  as  vigorous  rubbing  at  every  step  of  the  application. 
When  bandages  are  weak  or  when  extra  strength  is  desired,  the  band- 
age may  be  folded  to  and  fro,  each  duplication  being  smoothed  down 
with  the  hand  until  the  desired  number  of  layers  is  obtained.  This  area 
made  even  is  smoothly  covered  in  by  circular  turns.  In  general,  how- 
ever, six  to  ten  layers  of  a  properly  prepared  and  applied  bandage  are 
sufficient  to  give  strength. 

The  edges  of  the  bandage  may  be  finished  by  cutting  with  a  knife 
or  by  turning  down  over  the  outside  of  the  bandage  one-half  of  an  inch 
of  the  material  protecting  the  skin,  and  winding  over  the  turned-down 
part  one  or  two  turns  of  plaster  bandage.  This  leaves  the  edge  of  the 
bandage  protected  by  soft  material. 

The  surface  of  the  bandage  may  be  polished  when  it  is  nearly  dry  by 
rubbing  with  the  wet  hand  or  by  rubbing  with  the  plaster  paste  which 
is  found  in  the  bottom  of  the  bandage  pail. 

The  hands  of  the  surgeon  may  be  protected  by  the  use  of  thin  rub- 
ber gloves,  which  will  prevent  roughness  of  the  skin  caused  by  the  use 
of  plaster  of  Paris.  A  properly  applied  plaster  bandage  should  be 
sufficiently  dry  in  five  or  ten  minutes  from  the  time  that  the  applica- 
tion has  ceased. 

In  the  case  of  plaster  bandages  to  the  leg  which  are  inclined  to  slip 
down  over  the  ankles  and  give  trouble,  they  may  be  anchored  in  place 
by  the  use  of  a  strip  of  sticking  plaster,  three  or  four  feet  long  and  one 
inch  wide.  This  sticking  plaster  is  applied  to  the  outside  of  the  leg 
from  the  knee  down  under  the  sheet  wadding.  A  few  layers  of  plaster 
bandage  are  then  put  on,  and  the  strip  of  sticking  plaster  which  pro- 
jects below  the  lower  edge  of  the  bandage  is  then  turned  up  and  incor- 
porated in  the  bandage. 

Removal  of  Bandages. — If  it  is  desired  to  remove  the  bandage,  the 
plaster  should  be  moistened  by  means  of  a  medicine-dropper  with 
either  water  or  a  weak  solution  of  acetic  acid.  When  the  plaster  is  wet 
it  can  be  cut  with  ease  by  a  sharp  knife.  The  most  convenient  appara- 
tus is  either  a  knife  known  as  a  shoe  knife  or  a  knife  with  a  concealed 


PRACTICAL  DETAILS   OF  APPARATUS.  605 

blade  known  as  the  electrician's  knife.  It  is  not  desirable  to  make  the 
cuts  toward  the  patient's  skin,  but  parallel  to  or  away  from  it.  After 
the  application  of  a  plaster  jacket,  if  for  any  reason  it  is  feared  that 
there  may  be  constriction  of  the  circulation,  it  should  be  cut  down  in 
the  front  immediately  after  application,  so  that  it  may  be  sprung  open 
in  case  of  emergency.  If  sinuses  are  to  be  dressed,  or  if  for  any  rea- 
son it  is  desirable  to  remove  the  pressure  from  a  given  point,  windows 
may  be  cut  in  the  bandage.  It  is  also  possible  by  means  of  two  cuts  on 
the  opposite  sides  of  a  bandage  to  remove  a  lid,  through  which  the  joint 
or  limb  may  be  inspected,  and  which  can  be  replaced.  This  lid  can  be 
held  in  place  by  bandaging  with  a  wet  gauze  bandage.  When  bandages 
are  likely  to  be  worn  for  a  long  time,  and  especially  in  the  application  of 
spica  bandages  to  the  hip,  it  is  desirable  to  leave  a  strip  of  soft  gauze 
inside  of  the  bandage  for  cleansing  purposes.  The  two  ends  of  this 
above  and  below  the  bandage  should  be  left  sufficiently  long  to  be  fast- 
ened together.  By  pulling  this  strip  of  gauze  to  and  fro,  crumbs,  etc., 
are  removed.  The  indications  for  the  early  removal  of  a  plaster  band- 
age are  the  presence  of  constant  pain,  an  offensive  smell,  or  the  detec- 
tion of  a  serous  discharge  staining  the  outside  of  the  jacket.  These 
signs  point  to  harmful  pressure  or  the  formation  of  slough.  The  time 
which  a  plaster  jacket  or  bandage  should  be  worn  varies,  of  course, 
with  each  case. 

2.    CELLULOID    BANDAGES. 

Celluloid  jackets  or  bandages  are  light,  clean,  and  fairly  durable. 
They  are  not  dangerous  when  exposed  to  heat,  and  if  touched  with  a 
lighted  match  burn  with  about  the  same  rapidity  as  sheet  wadding. 
They  cannot  be  applied  directly  to  the  patient,  but  must  be  made  on  a 
dry  plaster  cast  of  the  limb  or  trunk.  To  manufacture  this  the  plaster 
bandage  is  applied  and  immediately  removed,  fastened  together,  one 
end  closed,  and  the  side  not  stopped  is  filled  with  a  plaster-of-Paris 
cream.  The  mould  is  then  removed  and  the  cast  smoothed,  dried,  and 
shellacked.  For  the  application  of  celluloid  splints  a  celluloid  paste  is 
made  by  dissolving  celluloid  chips  in  acetone  or  wood  alcohol.  This 
paste,  which  should  be  about  as  thick  as  ordinary  mucilage,  is  used  as 
a  paint  to  cement  together  and  harden  the  layers  of  some  cloth  placed 
over  the  cast.  This  cloth  may  consist  of  cheesecloth  bandages,  stock- 
inet, or  undervests  similar  to  those  described  for  plaster  jackets.  Each 
layer  of  cloth  receives  several  coats,  each  one  of  which  is  allowed  to  dry. 
When  the  cloth  material  takes  up  no  more  celluloid,  another  layer  is 
added  and  painted  in  the  same  way.  From  six  to  ten  layers  of  the  kind 
of  undervests  described  for  plaster  jackets  are  required  to  make  a  dura- 
ble celluloid  jacket.  The  thickness  of  the  bandage  in  each  case  must 
be  a  matter  of  individual  judgment.     After  a  sufficient  thickness  has 


6o6 


ORTHOPEDIC  SURGERY. 


been  reached  it  is  most  important  to  leave  the  bandage  or  jacket  on  the 
cast  until  it  is  thoroughly  dry  inside  and  out ;  otherwise  it  will  warp 
when  taken  off.  When  it  is  thoroughly  dry  it  is  cut  and  removed,  the 
inside  finished  with  a  fresh  painting  of  celluloid,  the  edges  are  trimmed 
and  bound  with  leather,  the  jacket  is  perforated  by  holes  throughout, 
and  leather  straps  one  inch  wide,  containing  studs  or  lacings  from  one 
to  two  inches  apart,  are  sewed  to  the  jacket,  one  inch  or  more  from  each 
side  of  the  cut  extending  its  entire  length.  For  the  use  of  plates  and 
splints,  for  the  forearm,  for  instance,  sheet  celluloid  or  pyroline  may  be 
used,  of  a  size  from  one-thirty-second  to  one-quarter  of  an  inch  thick, 
which  is  softened  in  hot  water  and  shaped  to  the  cast  by  binding  it  on 
with  rubber  tubing  wound  on  the  stretch,  the  cast  and  celluloid  being 
immersed  in  boiling  water  until  the  celluloid  is  shaped  to  the  cast. 
The  edges  should  be  smoothed  off  with  a  file,  and  the  surface  of  the 
celluloid  may  be  polished  if  desired.  The  white  variety  of  celluloid  is 
more  brittle  than  the  transDarent. 


3.    LEATHER    SPLINTS    AND    JACKETS. 

Moulded  leather  splints  and  jackets  are  made  from  oak-tanned  Eng- 
lish leather,  which  should  not  be  "filled"  or  "stuffed."  The  finished 
leather  is  not  useful  for  this  purpose.     The  leather  is  cut  of  the  desired 

pattern  and  softened  by  soaking  in 
water.  When  it  is  thoroughly  flex- 
ible it  is  stretched  over  a  plaster  cast 
of  the  limb  or  trunk  and  made  to 
conform  to  all  the  curves  of  it. 
This  may  be  accomplished  by  fasten- 
ing one  edge  and  hammering  or 
pressing  it  to  fit  the  hollows  and  fast- 


ening it  by  tacks  on  the  other  edge 
when  it  is  properly  moulded,  or  it 
may  be  wound  on  to  the  cast  by 
means  of  a  rope  encircling  it  in  close- 
ly fitting  turns.  After  being  shaped 
it  is  allowed  to  dry  on  the  cast  and 
removed.  It  will  retain  the  shape 
which  it  assumed  when  wet,  if  it  is 
thoroughly  dry.  If  it  is  wished  to 
stiffen  the  leather  in  order  to  secure 
a  firmer  support,  especially  in  the  case  of  jackets,  the  moulded  leather 
splint  is  painted  with  hot  bayberry  wax  until  it  ceases  to  absorb  it,  and 
it  is  then  allowed  to  dry.  The  bayberry  wax  discolors  the  leather  some- 
what and  gives  a  dull  finish.     If  it  is  desired  to  have  a  highly  polished 


Ptg, 


546.— Stiff    Jacket    Split   and     Laced. 
(Children's  Hospital  Report.) 


PRACTICAL  DETAILS   OF  APPARATUS.  607 

and  non-absorbent  surface,  the  jacket  is  now  painted  with  a  solution  of 
shellac  inside  and  outside  and  allowed  to  dry  thoroughly.  Several 
coats  are  necessary.  This  forms  a  fairly  durable  finish,  which  in  time 
softens  somewhat  under  the  influence  of  heat  and  perspiration  and 
pressure.  Jackets  and  splints  finished  in  this  way  do  not  need  to  be 
reinforced  with  steel  unless  a  great  deal  of  pull  or  pressure  is  coming 
upon  them.  If  desired  they  can  be  reinforced  with  strips  of  steel  fast- 
ened on  the  outside  and  riveted  to  the  jacket.  Such  steels  may  be  pro- 
tected from  rust  by  nickel-plating  or  may  be  covered  with  kid  sewed 
over  them.  Jackets  and  splints  should  be  provided  with  the  leather 
lacings  mentioned  in  speaking  of  celluloid  jackets. 

4.    ANTERO-POSTERIOR    SUPPORT    FOR    POTT'S    DISEASE. 

The  apparatus  consists  of  four  parts:  {a)  T%vo  uprights,  {b)  A  bot- 
tom piece.     {/)    Tzvo  shonlder pieces,     {d)   One  or  tzvo  cross  bars. 

(a)  The  uprigJits  reach  from  the  seventh  cervical  vertebra  to  one 
inch  below  the  posterior  superior  spine  of  the  ilium.  They  should  run 
on  each  side  of  the  spine  over  the  transverse  processes.  They  are 
curved  to  fit  the  tracing  of  the  spine  made  \n\\\\  the  child  lying  on  the 
face  and  taken  over  the  transverse  processes  of  the  spine.  Some  alter- 
ation in  this  curve  may  be  necessary  to  suit  the  standing  position. 
For  a  child  ten  years  old  the  uprights  should  be  made  one-half  of  an 
inch  wide  and  about  one-sixteenth  of  an  inch  thick,  being  made  of  No. 
8  gauge  cast  steel.  There  should  be  a  pad  plate  on  each  upright,  reach- 
ing from  the  level  of  the  highest  point  of  the  deformity  to  two  vertebrae 
below  the  lower  part  of  the  deformity.  They  should  be  of  spring  steel 
gauge  No.  16,  three-quarters  of  an  inch  wide,  shaped  to  fit  the  curve  of 
the  upright  and  also  curved  from  side  to  side  if  necessary  to  fit  the  lat- 
eral contour  of  the  deformity ;  otherwise  they  may  bear  only  on  the 
inner  edge.  They  are  fastened  to  the  upright  by  a  rivet  at  their  top 
end,  and  if  increased  pressure  is  desired  they  may  be  wedged  forward 
from  the  upright.  They  are  covered  with  thick,  firm  felt  or  with 
leather.  They  may  also  be  made  of  celluloid  or  hard  rubber  accurately 
fitted  to  the  contour  of  the  deformity,  but  the  latter  are  difficult  to 
make  comfortable  and  adjust. 

{b^  Bottom  Pieces. — The  bottom  pieces  consist  of  two  vertical  pieces 
behind  and  to  the  inner  side  of  the  trochanter.  These  are  joined  above 
the  posterior  superior  spines  of  the  ilium  by  a  transverse  piece  rounded 
posteriorly  to  fit  the  contour  of  the  sacrum  and  not  strike  bony  promi- 
nences. The  whole  bottom  piece  should  thus  consist  of  one  piece, 
shaped  like  an  inverted  U,  finished  below  with  circular  plates,  the  size 
of  a  fifty-cent  piece,  padded  with  felt,  covered  or  not  with  leather.  The 
vertical  measure  for  the  bottom  piece  should  be  taken  from  above  the 


6o8 


ORTHOPEDIC  SURGERY. 


posterior  superior  spine  to  one  inch  above  the  level  of  the  tuberosity  of 
the  ischium.     The  lateral  measurement  consists  of  the  distance  between 
the  post-trochanteric  fossEe.     The  material  is  the  same  as  the  upright. 
((f)   T%vo  Sho2ilder  Pieces. — The  shoulder  pieces  are  two  in  number 
and  separate.     They  are  of  the  same  width  as  the  upright,  are  made  of 


Fig.  547.— Antero-posterior  Support  for  Pott's  Disease. 

a  flexible  steel,  No.  14  gauge,  one-sixteenth  of  an  inch  thick,  and  are 
riveted  to  the  top  of  each  upright.  They  are  bent  outward  on  the  fiat 
at  an  angle  of  about  forty-five  degrees,  and  are  also  curved  downward  to 
conform  to  the  curve  of  the  shoulder.  They  should  reach  from  the  top 
of  the  upright  to  the  forward  edge  of  the  trapezius.  The  measurement 
is  the  distance  from  an  inch  or  more  below  the  top  of  the  upright  to  the 


PRACTICAL  DETAILS    OF  APPARATUS. 


609 


forward  edge  of  the  trapezius.     The  curve  outward  begins  at  the  top  of 
the  upright. 

(c/)  Cross  Bars. — These  are  fiat  transverse  bars.  The  first,  in 
length  is  shghtl}/  less  than  the  breadth  of  the  trunk  at  the  axillary  line. 
It  is  fastened  to  the  uprights  at  a  level  slightly  below  that  of  the  axilla, 
and  if  necessary  should  be  bent  backward  in  its  outer  part  so  as  not  to 
bear  on  the  scapulae.  The  measurement  is  as  given;  the  material 
should  be  the  same  width  as  the  upright,  made  of  sheet  steel,  gauge 
No.  14.  A  second  cross  bar  may  be  added  two  or  three  inches  below 
the  one  described  and  slightly  shorter  than  the  other,  and  in  length  is 
less  than  the  breadth  of  the  trunk.  It  can  be  omitted  in  thin  patients. 
These  pieces  are  fastened  to  the  upright  by  stout  rivets,  the  edges  are 


Fig.  548. — Apron  for  Use  with  Antero-posterior  Spinal  Support, 

smoothed  and  rounded,  and  all  the  parts  should  be  fastened  to  the  pos- 
terior surface  of  the  uprights. 

Buckles. — Brass  buckles,  seven-eighths  of  an  inch  in  width,  should 
be  fastened  on  leather  tabs  and  riveted  to  the  brace  by  means  of  holes 
drilled  in  it.  There  should  be  one  pair  at  the  bottom  of  the  U  piece, 
and,  if  perineal  straps  are  to  be  used,  two  pairs.  A  pair  should  be 
fastened  to  the  top  of  the  U  piece,  and  in  larger  children  another  pair 
to  the  middle.  There  should  be  a  buckle  at  each  end  of  each  cross 
bar.  In  place  of  a  buckle  at  the  end  of  the  shoulder  piece,  which  is 
unsightly  and  causes  the  clothes  to  stand  away  from  the  shoulders,  a 
short  leather  strap  should  be  fastened  on  the  top  end  of  each  upright, 
and  to  these  straps  should  be  attached  the  axillary  straps  and  another 
one  to  be  described,  which  is  used  in  certain  cases. 

Apron. — The  brace  is  held  to  the  body  and  made  efficient  as  a  lever 
by  means  of  an  apron  covering  the  anterior  surface  of  the  body  and 
fastened  to  the  brace  at  several  levels.  This  apron  is  made  of  stout 
39 


6io  ORTHOPEDIC  SURGERY. 

cloth  known  as  Hadley  sheeting.  The  width  of  this  is  from  the  mid- 
dle line  of  one  side  of  the  body  to  the  middle  line  on  the  other ;  roughly 
it  might  be  described  as  ending  at  the  anterior  axillary  line.  Above  it 
should  not  reach  as  far  up  as  the  top  of  the  sternum ;  below  it  should 
extend  to  the  symphysis  pubis.  The  upper  corners  are  cut  out  in  front 
of  the  shoulders  in  a  sweep,  concave  downward  and  inward.  The 
apron  is  smoothly  fitted  to  the  curves  of  the  body,  especially  of  the 
abdomen,  by  means  of  gores  or  gussets  at  the  edges  if  necessary. 
Wrinkling  may  be  prevented  by  stiffening  the  apron  at  the  waist  with 
corset  steels  or  bones.  The  edges  of  the  apron  are  finished  by  one-half 
of  an  inch  hemming. 

Fmish  of  Brace.—SNhQn  the  splint  is  finished  it  should  be  nickel- 
plated,  blued,  or  japanned  to  prevent  rusting.  The  skin  of  the  back 
should  be  protected  from  the  brace  above  and  below  by  a  square  of  felt 
or  leather  loosely  attached  at  the  top  and  at  the  U-piece  below.  This 
should  cover  only  the  points  of  contact  with  the  skin.  The  shoulder 
piece,  if  projecting  beyond  the  uprights,  should  be  covered  with  moose 


Fig.  549-— Taylor's  Chest  Piece. 


hide,  thick  chamois,  or  felt.  If  the  anterior  surface  of  the  brace  rusts, 
which  it  should  not  do  if  nickel-plated,  the  clothes  of  the  patient  may 
be  protected  from  rust  by  laying  a  pad  of  felt  under  the  brace. 

Straps  from  the  Apron  to  the  ^m^6\— These  are  made  of  webbing 
tape,  one  inch  wide,  costing  four  cents  a  yard.  A  strap  on  each  side  at 
the  level  of  the  axilla  is  sewed  to  the  edge  of  the  apron  and  passes 
around  to  fasten  into  the  buckle  at  the  end  of  the  upper  cross-bar. 
There  should  be  a  strap  on  each  side  on  a  level  with  the  top  of  the  U- 
piece  to  fasten  to  the  buckle  there.  There  should  be  a  strap  on  each 
side  at  the  bottom  of  the  apron  to  fasten  to  the  buckle  at  the  bottom 
of  the  U-piece.  In  larger  children,  where  there  is  a  buckle  in  the  mid- 
dle of  the  U-piece,  there  should  be  an  extra  pair  of  straps  on  a  level 
with  these  buckles.  Two  longer  straps,  one  carrying  a  buckle,  should 
be  sewed  to  the  middle  of  the  apron,  and  these  pass  around  the  back 
outside  of  the  brace  and  are  buckled  together,  forming  an  additional 
strap.     At  the  top  of  the  brace  an  axillary  strap  should  be  sewed  on 


PRACTICAL  DETAILS   OF  APPARATUS. 


6ii 


each  side  to  the  leather  strap  fastened  to  the  top  of  the  cross-bar. 
These  axillary  straps  pass  around  the  shoulders  and  through  the  axilla 
to  the  buckle  in  the  end  of  one  of  the  cross-bars  from  the  tip  of  the 
shoulder-piece.  To  the  leather  on  the  top  of  the  shoulder-piece  is  also 
sewed  a  strap  on  each  side,  which  passes  to  buckles  sewed  at  the  top 
edge  of  the  apron.  These  straps  should  be  padded  by  being  wound 
with  sheet  wadding  and  covered  with  canton  flannel  or  a  soft  leather. 
Perineal  straps  padded  in  the  same  way,  one  on  each  side,  should  pass 


Fig.  550. — Oval  Ring  Head  Support  Added  to  tee  Antero-posterior  Support.     (See  Pig.  76.) 

from  the  lower  end  of  the  apron  at  a  point  opposite  the  top  of  the  fold 
in  the  groin,  to  a  buckle  to  the  bottom  of  the  U-piece.  They  are  an  im- 
portant addition  to  the  security  of  the  brace  and  are  essential  in  disease 
of  the  lower  part  of  the  spine  or  when  the  brace  tends  to  ride  up. 
They  are  not  to  be  used  in  connection  with  head  supports. 

A  leather  gorget  may  be  used  for  the  upper  part  of  the  chest  when 
it  is  desirable  to  prevent  the  pressure  on  the  chest  from  the  top  of  the 
apron.  It  is  used  independently  of  the  apron  and  the  top  of  the  apron 
is  cut  away.     When  this  is  done  the  axillary  end  of  the  leather  gorget 


6 12  ORTHOPEDIC  SURGERY. 

should  be  finished  with  webbing  straps,  one  on  each  side,  which  are 
fastened  to  extra  buckles  placed  at  the  top  of  the  U-piece  of  the  brace. 
Head  supports  are  needed  in  connection  with  the  antero-posterior 
support  or  the  plaster  jacket  in  Pott's  disease  of  the  upper  part  of  the 
spinal  column. 

5.    OVAL    RING    HEAD    SUPPOR'^:. 

This  is  to  be  worn  in  connection  with  the  antero-posterior  spinal 
support,  and  consists  of  {a)  an  oval  ring,  {b)  a  spindle,  and  {c)  a  socket. 

(a)  The  oval  ring  should  extend  from  the  occiput  behind  to  the  tip 
of  the  chin  in  front.  In  width  it  is  slightly  wider  than  the  distance  be- 
tween the  angles  of  the  jaw.  It  is  hinged  at  the  angle  of  the  jaw  at 
one  side  to  open  in  a  horizontal  plane,  and  on  the  opposite  side  at  the 
same  point  is  fastened  when  closed  by  a  ring  clasp.  It  is  made  of  one- 
quarter  of  an  inch  spring  steel. 

The  antero-posterior  diameter  is  from  just  below  the  occipital  pro- 
tuberance to  the  tip  of  the  chin;  the  lateral  diameter  is  the  width  be- 
tween the  angles  of  the  jaw,  to  which  should  be  added  one-half  of  an 
inch  or  less  on  each  side. 

At  the  anterior  end  of  the  oval  ring  there  should  be  a  plate  of  hard 
rubber  or  celluloid  moulded  to  the  shape  of  the  chin.  This  is  riveted 
to  a  sheet-tin  bridge,  three-quarters  of  an  inch  in  width  and  one  and 
one-quarter  inches  long,  soldered  to  the  front  of  the  ring.  An  occipital 
pad  is  required  of  hard  rubber  or  thick  leather,  fastened  to  the  inside 
of  the  posterior  part  of  the  ring  and  slanting  backward  to  give  support 
to  the  occiput.  This  pad,  made  of  sheet  steel  covered  with  leather, 
should  be  approximately  shaped  to  the  contour  of  the  back  of  the  head. 
To  the  middle  of  the  back  of  the  ring  is  riveted  a  piece  of  steel  suffi- 
ciently thick  to  be  pierced  with  a  vertical  hole,  into  which  is  inserted  the 
top  of  the  spindle  which  connects  the  ring  with  the  top  of  the  brace 
and  permits  horizontal  rotation. 

{li)  Spindle. — ^The  steel  spindle  which  connects  the  ring  with  the 
brace  below  fits  into  a  socket  riveted  to  the  two  uprights  of  the  brace. 
The  spindle  should  be  bent  in  such  an  antero-posterior  cur\^e  that  w^hen 
the  brace  is  applied  the  oval  ring  should  touch  the  occiput  and  chin  at 
a  proper  angle.  The  spindle  is  prevented  from  dropping  down  in  the 
socket  of  the  brace  by  a  set  screw  passing  through  the  back  half  of  the 
socket.  By  the  use  of  this  screw  the  spindle  may  be  raised  or  lowered 
as  desired. 

The  length  of  the  spindle  is  a  distance  from  a  point  just  below  the 
occipital  protuberance  to  the  point  on  the  uprights  selected  for  the 
socket.  The  spindle  is  forged  from  three-eighths  of  an  inch  machine 
steel,  and  in  its  lower  part  is  one-quarter  of  an  inch  wide  and  thick, 
being  flattened  on  the  anterior  surface  and  curved  on  the  posterior.     In 


PRACTICAL   DETAILS    OF  APPARATUS. 


613 


its  upper  third  it  becomes  circular,  and  terminates  above  in  a  vertical, 
circular  pin,  one-sixteenth  of  an  inch  in  diameter,  fitting  accurately  into 
the  socket  at  the  back  of  the  oval  ring.  As  a  guide  to  the  shape  of  the 
spindle,  a  tracing  should  be  taken  with  a  strip  of  lead  in  the  middle  line 
at  the  back,  running  from  the  occiput  to  the  point  where  the  socket  is 
to  be  attached  to  the  uprights. 

(r)  Socket. — The  socket  consists  of  a  flat  steel  bar,  riveted  at  each 
end  to  the  uprights  of  the  brace.  In  the  middle  it  is  sufficiently  thick 
to  allow  a  hole  to  be  drilled  in  it  from  above  downward,  through  which 
passes  the  lower  part  of  the  spindle.  This  piece,  of  machine  steel, 
should  be  one-half  of  an  inch  wide  and  three-cjuarters  of  an  inch  thick. 
The  dimensions  of  the  hole  for  the  spindle  are  the  same  as  those  given 
for  the  lower  part  of  the  spindle,  which  fits  closely  into  the  hole.  The 
spindle  is  pre\'ented  from  slipping  down  by  two  set  screws,  which  turn 
in  threads  drilled  in  the  posterior  half  of  the  socket  where  the  spindle 
passes  through.  The  parts  described  are  finished  in  the  same  way  as 
the  rest  of  the  brace. 


6.    ANTERIOR    HEAD    SUPPORT. 

The  anterior  head  support  is  to  be  attached  to  the  antero-posterior 
support  or  the  plaster  jacket.  It  consists  of  (a,  b)  tivo pieces  of  z>jire, 
and  {c~)  an  occipital  piece  of  steel. 

(a)  The  chest  and  shoulder  piece  is  a  U-shaped  piece  of  wire  bent 
to  rest  on  the  shoulders  and  on  the 
chest,  not  bearing  on  the  clavicles. 

The  U-piece  which  is  applied  to 
the  chest  and  shoulders  is  meas- 
ured from  the  level  of  the  xiphoid 
cartilage  to  one  inch  posterior  to  the 
anterior  border  of  the  trapezius. 
These  strips  are  vertical.  The  width 
of  the  bottom  of  the  U-piece  is 
the  horizontal  distance  between 
the  middle  of  the  clavicles.  It  is 
bent  to  follow  the  lateral  contour 
of  the  chest,  and  from  below  up- 
ward lies  closely  against  the  chest 
and  shoulders,  but  is  bent  out  over  ^i°-  551 
the  clavicles. 

(7;)  The  other  piece  of  wire,  the  chin-piece,  is  bent  to  follow  the 
outline  of  the  chin  and  the  ramus  of  the  jaw.  The  posterior  ends  of 
the  chin-piece  are  bent  vertically  downward  just  back  of  the  ramus  of 
the  jaw,  and  welded  or  soldered  to  the  chest-piece  at  points  posterior  to 
the  clavicle  on  each  side. 


Anterior  Head  Support.     (See 
Fig.  77.) 


6 14  ORTHOPEDIC  SURGERY. 

(c)  The  occipital  piece  consists  of  a  strip  of  cast  steel  wire,  one- 
quarter  of  an  inch  thick,  running  horizontally  behind  the  head  and  bent 
around  the  wire  upright  on  one  side  to  form  a  hinge  and  secured  to  the 
opposite  wire  upright  by  a  hook  catch  made  by  bending  over  its  end. 

The  length  of  the  anterior  horizontal  portion  is  the  distance  from 
just  behind  the  ramus  of  the  jaw  to  the  tip  of  the  chin.  Its  width  is 
the  distance  between  the  outer  surface  of  the  mastoid  processes  plus 
one-half  of  an  inch  or  less  on  each  side.  The  height  of  the  vertical 
portion  of  the  chin-piece,  where  its  posterior  ends  are  bent  down  to 
unite  with  the  shoulder-piece,  is  measured  from  the  tip  of  the  ear  to 
the  point  where  the  highest  portion  of  the  shoulder-piece  passes  over 
the  shoulder.  This  vertical  portion  slopes  outward  from  the  ramus  of 
the  jaw  to  the  shoulder  part  of  the  U-piece.  The  measure  of  the  occi- 
pital part  of  the  brace  is  the  distance  between  the  tips  of  the  ears 
measured  as  a  curve,  not  touching  the  skin,  at  a  level  just  below  the 
occipital  protuberance. 

To  prevent  chafing  of  the  skin,  pads  are  attached  under  the  tip  of 
the  chin,  as  described  in  the  oval  ring.  The  occipital  piece  is  padded 
behind  with  thick  felt  covered  with  leather.  To  the  portions  of  the  U- 
piece  of  the  brace  passing  over  the  shoulder  and  across  the  sternum  are 
soldered  strips  of  thick  machine  steel,  three-quarters  of  an  inch  wide 
and  one-quarter  of  an  inch  thick,  curved  to  fit  the  brace,  perforated  at 
their  edges  with  small  holes,  so  that  there  may  be  stitched  to  the  pos- 
terior surface  of  these  steel  pieces  felt  pads  covered  with  chamois  or 
kid.  The  material  used  for  constructing  this  head-piece  is  cast  steel, 
one-quarter  of  an  inch  in  diameter. 

The  support  is  fastened  to  the  back  brace  by  means  of  strips  of 
webbing,  one  inch  wide,  riveted  to  the  upper  part  of  the  U-piece. 
These  straps,  which  should  be  padded,  pass  over  the  shoulders  and  are 
fastened  to  buckles  riveted  to  the  upper  ends  of  the  antero-posterior 
support.  Similar  webbing  straps  are  also  attached  to  the  lower  angles 
of  the  U-piece  and  pass  horizontally  around  the  sides  of  the  chest,  to 
be  fastened  to  buckles  attached  to  the  middle  of  the  antero-posterior 
support. 

If  it  is  desired  to  give  greater  security  to  the  head,  upright  strips  of 
steel  may  be  attached  to  the  posterior  part  of  either  of  the  forms  of 
support  just  described,  the  oval  ring  or  the  antero-posterior  support.' 
These  strips  are  bent  to  conform  to  the  posterior  contour  of  the  head, 
and  pass  upward  one  inch  behind  the  mastoid  processes  to  the  level  of 
the  parietal  eminences.  They  are  made  of  spring  steel,  one  and  one- 
quarter  inches  vride  and  one-sixteenth  of  an  inch  thick,  forming  a 
padded  plate  at  the  top  riveted  on  to  the  upright.  The  length  of  the 
upright,  made  of  one-quarter  of  an  inch  round  cast  steel,  is  the  distance 
from  the  horizontal  ring  to  the  parietal  eminence.     They  are  provided 


PRACTICAL  DETAILS    OF  APPARATUS.  615 

at  their  upper  ends  with  buckles,  which  are  riveted  to  them,  which 
serve  to  secure  a  padded  webbing  strap  passing  forward  round  the 
forehead  from  one  upright  to  the  other.  They  are  also  provided  at  the 
level  of  the  mastoid  processes  with  a  buckle  facing  inward  on  each  up- 
right, which  serves  to  secure  a  supporting  strap  passing  behind  the  oc- 
ciput. The  tightening  of  these  straps  steadies  the  head,  and,  with  the 
chin-piece,  holds  it  firmly. 

7.    THOMAS    COLLAR. 

The  original  Thomas  collar  consisted  of  a  strip  of  calf  skin  folded  on 
itself  to  the  depth  of  from  four  to  six  inches,  the  two  free  ends  being 
stitched  together  in  an  irregular  curved  line.  In  the  centre  of  the  por- 
tion to  be  placed  under  the  chin  the  stitching 
was  from  four  to  six  inches  below  the  upper 
border.  At  the  point  below  the  ear  the 
stitching  was  two  inches  from  the  upper  bor- 
der. At  the  posterior  portion  the  lower 
border  of  the  stitching  was  three  inches  be- 
low the  upper  border.  Sawdust  was  pressed  ^^''■'''%'^^i^^^^'^''''^"' 
in   between   the   folds   of    leather  held    below 

by  the  stitching  and  above  by  the  folded  top  of  the  leather.  Straps 
and  buckles  were  attached  to  the  posterior  portion  of  the  collar  stitched 
around  the  neck.  A  greater  or  less  amount  of  sawdust  was  packed  into 
the  cavity,  in  order  to  increase  or  diminish  the  amount  of  support. 
This  collar,  which  can  be  made  by  any  saddler,  is  somewhat  awkward 
in  shape  but  readily  made.  As  a  substitute  for  this,  a  collar  stock  can 
be  made  of  stiffened  leather  similar  to  what  is  used  for  leather  jackets, 
reinforced  by  steel  or  phosphor  bronze  and  padded  with  felt.  The 
length  of  the  collar  or  stock  should  be  sufficient  to  encircle  the  neck 
and  fasten  behind  without  overlapping. 

8.    QUADRILATERAL    BACK    BRACE.' 

The  design  of  this  brace  is  to  combine  with  the  antero-posterior 
leverage  action  of  the  Taylor  back  brace  the  power  of  checking  rotation 
obtained  in  the  plaster-of-Paris  jacket.  The  entire  upper  chest  is  left 
free  from  the  pressure  of  the  apron,  and  the  shoulder  girdle  is  used  as 
a  point  of  counter-pressure  for  the  axillary  straps.  This  is  made  pos- 
sible by  the  fastening  of  the  scapulae  under  the  widely  separated  up- 
rights, which  restrict  their  motion  upon  the  thorax  within  very  narrow 
limits.  It  consists  of  {ci)  a  pelvic  band;  (/;)  two  uprights;  (r)  a  top 
bar;  (^)  a  pad  plate  bar;  (r)  an  apron. 

'John  Dane:  Trans.  Am.  Orth.  Assn.,  xiii.,  70. 


6i6 


ORTHOPEDIC  SURGERY. 


id)  T\iQ  pelvic  band  is,  made  of  No.  15  gauge  sheet  steel,  and  is  bent 
to  fit  the  curve  of  the  pelvis,  circling  it  behind  at  a  point  just  above 
the  trochanters.  Its  anterior  ends  reach  to  the  anterior  superior  spines. 
{b)  The  uprights,  made  of  No.  12  gauge  cast  steel,  and  riveted  to 
the  pelvic  band  a  little  outside  of  the  posterior  superior  spines.  They 
extend  upward  to  one-half  of  an  inch  above  the  spines  of  the  scapulae. 
To  their  ends  are  riveted  the  descending  arms  of  the  top  bar.  These 
uprights  are  bent  so  as  to  follow  the  curve  of  the  flanks,  but  not  to 

rest  upon  the  skin  until  they  pass 
over  the  scapulae,  from  which  point 
they  should  press  upon  the  skin 
when  the  shoulder-straps  are  tight- 
ened. 

{c)  The  Top  Bar. — This  is  made 
of  the  same  size  of  metal  as  the 
uprights.  Its  length  is  the  diameter 
of  the  back,  taken  from  one-half  of 
an  inch  inside  the  glenoid  rim  of 
the  scapulas,  when  the  shoulders 
are  pulled  backward.  Each  end  of 
this  bar  is  bent  at  a  right  angle 
downward  and  continued  for  one 
inch.  To  these  descending  arms 
the  upper  extremities  of  the  up- 
rights are  riveted. 

{d)  The  Pad-Plate  ^^7-.— This 
is  a  horizontal  bar,  No.  14  gauge 
sheet  steel,  fastened  to  the  uprights 
by  means  of  a  flat-headed  screw  at 
the  level  of  the  kyphos.  Its  central 
portion  is  curved  sharply  backward 
so  as  to  clear  the  spinous  process  of 
the  vertebrae.  On  the  slope  of  this 
curve  on  each  side  are  riveted  the 
pad  plates.  These  are  flat  strips  of  No.  1 8  gauge  sheet  steel,  one-half 
of  an  inch  wide  and  from  one  and  one-half  to  three  inches  long.  The 
distance  between  them  is  enough  to  insure  their  pressure  falling  upon 
the  transverse  processes  of  the  vertebrae.  To  facilitate  adjustment  of 
the  pad-plate  bar  the  opening  for  the  screws  that  hold  its  ends  to 
the  uprights  is  made  in  the  form  of  slits,  one-half  of  an  inch  in 
length. 

Three  buckles  are  riveted  to  the  uprights,  one  on  each  side,  the 
upper  one  just  below  the  axilla,  the  others  equally  spaced  below.  One 
more  pair  of  buckles  are  riveted  to  the  ends  of  the  pelvic  band.     One 


-Quadrilateral  Back  Brace. 


PRACTICAL  DETAILS   OF  APPARATUS.  617 

end  of  a  padded  strap  is  riveted  to  the  outer  end  of  the  top  bar  on  each 
side. 

The  frame  of  the  brace  is  wound  with  canton  flannel  or  covered  on 
the  side  next  the  skin  with  leather.  Each  pad  plate  has  a  felt  pad, 
three-eighths  of  an  inch  thick,  sewed  to  its  anterior  surface.  These  can 
be  frequently  changed  as  occasion  may  arise. 

{/)  The  Apron. — This  is  cut  from  sole  leather,  one-sixteenth  of  an 
inch  thick.  Its  length  extends  from  the  level  of  the  ensiform  to  the 
top  of  the  pubis  in  the  median  line ;  from  the  level  of  the  ensiform  to 
the  anterior  superior  spines  on  the  sides.  Its  width  is  the  diameter  be- 
tween the  anterior  spines.  Straps  of  webbing  are  sewed  to  this  on  each 
side  opposite  the  lower  buckles  on  the  brace,  the  upper  pair  of  buckles 
taking  the  ends  of  the  padded  straps  that  come  from  the  top  bar  of  the 
brace. 

Quadrilateral  Back  Brace  with  Head  Support. 

The  brace  is  similar  to  that  just  described,  with  the  addition  of  a 
second  horizontal  bar  connecting  the  uprights  from  one  to  two  inches 
below  the  top  bar.  In  cases  of  very  high  deformity  the  pad-plate  bar 
can  be  made  to  take  its  place. 

The  head  support  consists  of:  ia)  Two  uprights;  ((^)  the  occipital 
strap ;  (c)  the  frontal  strap. 

ia')  The  uprights.  Starting  as  flat  forged  steel  bars,  one-half  of  an 
inch  wide  and  one-eighth  of  an  inch  thick,  from  one  inch  below  the 
second  horizontal  bar,  they  are  carried  straight  upward  to  a  point  one 
inch  below  the  occiput ;  then  as  round  rods  they  are  curved  upward  and 
outward  to  a  point  one  inch  above  and  one-half  of  an  inch  behind  the 
ear ;  then  forward  close  to  the  head  as  flat  bars  to  the  level  of  the  pos- 
terior part  of  the  forehead.  As  they  pass  around  the  occiput  behind 
they  are  one-half  of  an  inch  from  the  head.  These  uprights  pass 
through  guides  riveted  to  the  posterior  surface  of  the  top  and  second 
bars  of  the  brace.  The  guides  on  the  second  bar  are  perforated  with 
holes  and  finished  with  screws  for  holding  the  uprights  in  position. 
The  width  between  the  guides  should  be  a  little  less  than  the  trans- 
verse diameter  of  the  patient's  neck.  The  horizontal  flanges  are  cov- 
ered with  leather  on  their  inner  sides  where  they  grasp  the  head.  A 
buckle  is  riveted  to  the  anterior  end  of  each  horizontal  flange. 

{b)  The  occipital  strap  is  made  of  a  thin  strip  of  brass,  one-quarter 
of  an  inch  wide,  covered  with  calf-skin.  On  one  end  it  is  prolonged 
forward  for  one-half  of  an  inch  as  a  right-angled  arm.  This  is  riveted 
to  one  of  the  uprights  at  the  angle  where  it  becomes  horizontal.  Its 
other  end  is  free.  This  strap  is  padded  on  its  inner  side  with  thin  felt 
and  covered  with  leather.     On  the  free  end  this  leather  is  prolonged  as 


6i8  ORTHOPEDIC  SURGERY. 

a  strap  and  passes  through  a  buckle  riveted  to  the  outer  side  of  the 
other  upright  at  the  angle  where  that  becomes  horizontal. 

(<f)  Th.&  frontal  strap  is  made  of  calf -skin,  one  inch  wide  where  it 
crosses  the  forehead,  rapidly  tapering  to  the  diameter  of  the  buckles 
that  have  been  riveted  to  the  horizontal  arms  of  the  uprights.  Each 
end  of  this  strap  is  punched  with  a  series  of  holes  for  the  tongue  of  the 
corresponding  buckle. 

9.   THE    GAS-PIPE    BED    FRAME. 

The  gas-pipe  bed  frame  is  of  a  rectangular  form  and  is  made  of 
ordinary  gas  pipe,  the  size  of  the  gas  pipe  being  governed  by  the  size 
and  weight  of  the  patient.  What  is  known  as  •'  quarter-inch  "  pipe  is 
sufficiently  large  for  children,  and  three-eighths  of  an  inch  pipe  for 
adults  of  moderate  weight. 

Four  pieces  of  gas  pipe  are  threaded  at  their  ends  for  one  inch,  and 
are  attached  to  each  other  at  the  four  corners  by  four  elbows.     The 


'^f'*i8-"iiii"ll'"~      , 

Fig.  554.— Gas-Pipe  Frame. 


length  of  the  frame  is  the  height  of  the  patient,  with  the  addition  of 
four  inches.  The  width  of  the  frame  is  the  distance  between  the  axil- 
lary lines  or  a  little  less.  The  frame  is  covered  with  stout  cotton  cloth, 
generally  doubled.  This  cover  should  be  a  little  short  of  the  full 
length  of  the  frame  and  one  and  three-quarters  times  as  wide.  This 
passes  over  the  front  of  the  frame  and  around  its  sides,  and  is  secured 
behind  by  webbing  and  buckles,  which  are  sewed  to  its  under  side  at 
proper  intervals  or  is  laced  by  a  cord  stitched  through  the  edges  by 
means  of  a  sailor's  needle.  To  protect  the  cover  from  wrinkling  two 
tapes  are  run  from  the  top  and  two  from  the  bottom  of  the  cover  to 
the  top  and  bottom  of  the  frame.  The  cover  should  be  smoothly 
stretched  on  the  frame  and  should  lie  without  wrinkling.  When  the 
patient  must  not  be  lifted  for  the  use  of  the  bed  pan,  the  covering  is 
opened  by  two  cuts  intersecting  at  a  right  angle  opposite  the  pelvis. 
The  cut  flaps  are  sewed  back  to  the  back  part  of  the  covering,  and  the 
borders  of  the  cover  at  the  hole  are  protected  by  rubber  sheeting. 
The  cover  is  easily  renewed  when  stretched  or  soiled.  In  heavy  pa- 
tients, to  prevent  the  sides  of  the  frame  from  being  palled  together, 
they  are  braced  apart  by  a  flat  strip  of  machine  steel,  three-quarters  of 


PRACTICAL  DETAILS   OF  APPARATUS.  619 

an  inch  wide  and  one-quarter  of  an  inch  thick.     This  strip  is  bent  at 
the  ends  to  hook  over  the  pipe  at  the  sides  of  the  frame. 

If  it  is  desired  to  hokl  the  spine  in  a  position  of  hyperextension,  the 
sides  of  the  bed  frame  may  be  curved  upward  opposite  the  deformity 
to  any  desired  extent.  This  curve  may  be  a  gradual  one  or  a  section  of 
the  frame  may  be  elevated  by  an  abrupt  curve  above  and  below  it. 

10.    TRACTION    HIP    SPLINT. 

The  traction  hip  splint  consists  of:  {a)  A  horizontal  pelvic  band; 
{b)  an  outside  upright ;  and  {c)  two  or  three  posterior  bands  behind  the 
thigh  and  calf. 

{a)  ^\\Q,  pelvic  band  is  made  of  one  piece  of  flat  steel  curved  in  the 
shape  of  a  U,  which  passes  along  the  front  of  the  pelvis,  around  the  side 
on  which  is  situated  the  diseased  hip,  and  then  passes  along  the  poste- 
rior surface  of  the  pelvis.  The  anterior  part  of  the  pelvic  band  forms  a 
curved  right  angle  with  the  outer  surface  of  the  band,  which  is  some- 
what flattened,  but  where  the  outer  part  of  the  band  joins  the  posterior 
part  the  angular  curve  is  rounded  and  is  not  so  sharp  as  at  the  anterior 
angle.  The  measurements  of  the  pelvic  band  are  as  follows :  The  an- 
terior half  extends  from  the  point  at  the  middle  of  the  outside  of  the 
thigh  just  above  the  trochanter  to  a  point  just  beyond  the  opposite  an- 
terior superior  spine  of  the  ilium.  The  posterior  half  is  one  inch  longer 
than  the  anterior  half,  and  is  bent  in  a  more  gradual  curve,  as  has  been 
said.  The  pelvic  band  is  made  of  tire  steel.  No.  8  gauge,  and  one  inch 
wide.  It  is  forged  so  that  the  anterior  and  posterior  parts  are  parallel 
to  each  other  in  the  vertical  plane,  and  the  free  ends  are  rounded.  The 
pelvic  band  is  fastened  to  the  upright  at  an  inclination  of  twenty  de- 
grees from  a  right  angle,  the  posterior  part  being  higher  than  the  ante- 
rior. The  anterior  and  posterior  arms  of  the  pelvic  band  should  be 
separated  by  a  distance  of  one  inch  greater  than  the  antero-posterior 
distance  between  the  anterior  and  posterior  superior  iliac  spines.  The 
pelvic  band  should  form  a  right  angle  in  the  lateral  plane  with  the  up- 
right. 

Buckles  are  placed  on  the  pelvic  band,  two  in  front  and  two  be- 
hind, to  hold  the  perineal  bands  which  furnish  counter-traction  to  the 
extension  pull  downward.  At  the  back  they  are  situated  just  posteri- 
orly to  the  trochanters,  one  on  each  side.  The  perineal  bands  pass 
forward  at  the  side  of  the  perineum  to  buckle  on  the  anterior  arm, 
one  at  each  side  of  the  median  line.  These  buckles  should  be  placed 
as  close  together  in  front  as  is  possible  without  interfering  with  the 
genitals.  Another  buckle  is  fastened  to  the  anterior  end  of  the  pelvic 
band,  to  which  is  fastened  a  strap  passing  from  the  posterior  end.  The 
pelvic  band  is  padded  on  the  inside  with  a  strip  of  felt  and  covered  with 


620 


ORTHOPEDIC  SURGERY. 


leather  stitched  at  the  edges.  The  inside  of  the  band  should  be  cov- 
ered with  sheep-skin  and  the  outside  with  morocco  leather  or  calf-skin. 
The  buckles  are  riveted  on  through  the  leather  and  are  on  the  outside 
of  it.  The  leather  which  covers  the  pelvic  band  is  made  long  enough 
to  pass  beyond  the  end  of  the  posterior  arm  of  the  splint,  and,  passing 
around  the  outside  of  the  pelvis  of  the  patient,  is  buckled  into  the 


Fig.  555.— I^ong  Traction  Hip  Splint. 
(See  Figs.  119  and  122.) 


Fig 


56.— Side  View  of  the  Long- 
Traction  Appliance. 


buckle  on  the  anterior  arm  of  the  pelvic  band.  This  may  be  done  by 
means  of  a  webbing  strap,  seven-eighths  of  an  inch  wide,  passing  into 
a  seven-eighths-of-an-inch  buckle,  or  by  means  of  a  strap  of  leather 
riveted  to  the  leather  of  the  pelvic  band.  This  leather  strap  should 
be  one  and  one-quarter  inches  wide.  The  upright  is  finished  by  being 
nickel-plated,  blued,  or  japanned. 

{b)  The  2ipnght  runs  on  the  outside  of  the  leg,  from  a  point  on  a 
level  with  the  anterior  superior  spine  of  the  ilium  to  a  point  two  and 
one-half  inches  below  the  bare  heel.  It  should  be  straight,  except  in 
the  case  of  very  fat  patients,  when  it  should  bend  outward  in  its  upper 
third  to  follow  the  curve  of  the  hip.  The  bottom  of  the  upright  is 
flattened  from  side  to  side  for  a  distance  of  three  and  one-eighth 
inches.     After  being  flattened  at  this  point  it  should  measure  five-eighths 


PRACTICAL  DETAILS   OF  APPARATUS.  621 

vjf  an  inch  wide  and  one-quarter  of  an  inch  thick.  It  is  then  turned  in 
at  a  sharp  right  angle  to  the  upright  for  a  distance  of  two  and  one- 
half  inches,  and  the  part  coming  next  to  the  ground  is  forged  flat. 
After  running  inward  at  a  right  angle  to  the  upright  for  two  and 
Oiie-half  inches,  the  extreme  end  is  turned  up  at  a  right  angle,  running 
up  from  the  bottom  of  the  foot-piece  where  it  touches  the  ground 
a  distance  of  five-eighths  of  an  inch.  This  constitutes  the  bottom 
piece  of  the  splint,  to  which  a  windlass  arrangement  is  attached.  This 
consists  of  a  spindle,  three  inches  long  and  one-quarter  of  an  inch  in 
diameter,  passing  through  holes  drilled  in  the  upright  at  a  point  one- 
half  of  an  inch  from  the  bottom  of  the  splint  to  a  corresponding  hole  in 
the  turn  of  the  inner  part  of  the  foot-piece.  This  spindle  is  fastened 
in  place  by  a  pin  passing  through  it  on  the  outside  of  the  part  project- 
ing up  from  the  inside  of  the  foot-piece.  It  projects  beyond  the  outer 
surface  of  the  upright  for  a  distance  of  three-eighths  of  an  inch.  Next 
to  the  upright  and  outside  of  it  is  fastened  upon  the  spindle  a  ratchet 
wheel,  one-half  of  an  inch  in  diameter,  which  is  controlled  by  a  spring 
and  stop,  one  and  one-eighth  inches  in  length,  fastened  to  the  upright 
above  it  by  a  pin.  The  end  of  the  spindle  terminates  in  a  square  end- 
piece  fitted  to  a  clock  key.  By  means  of  this  attachment  it  can  be 
turned  only  in  one  direction.  The  spindle  is  partially  split  at  its  middle 
for  the  insertion  of  webbing  straps. 

The  upright  at  its  top  is  fastened  to  the  pelvic  band  in  one  of  two 
ways.  In  small  children,  where  there  is  not  very  much  strain,  the 
upper  end  of  the  upright  is  flattened  out,  forming  an  angle  of  twenty 
degrees  with  the  upright  and  curved  to  lie  close  to  the  pelvic  band.  In 
its  flattened  part  three  holes  are  drilled,  and  corresponding  to  them 
three  holes  are  drilled  in  the  pelvic  band,  and  by  means  of  these  holes 
the  pelvic  band  is  fastened  to  the  upright  by  three  strong  one-eighth- 
of-an-inch  rivets.  For  large  patients,  where  greater  strain  is  liable,  a 
stronger  connection  is  necessary.  In  this  case  a  heavy  pelvic  band  is 
necessary,  and  the  upright  is  not  flattened  at  its  top  but  is  left  square. 
A  short  steel  strip  is  then  forged  in  such  a  way  that  it  passes  along  the 
pelvic  band  in  front  of  the  upright  for  a  distance  of  one  inch.  It  then 
curves  out  and  round  the  upright  and  back  to  the  pelvic  band,  which  it 
follows  for  one  inch  posterior  to  the  upright.  In  front  of  the  upright 
and  back  of  it  holes  are  drilled  in  this  strip,  and  holes  are  drilled  in  the 
pelvic  band  opposite  to  them,  through  which  stout  rivets  are  passed. 
A  hole  is  also  drilled  through  the  strip  of  steel  passing  outside  the  up- 
right, through  the  upright,  and  through  the  pelvic  band,  and  through 
this  hole  another  rivet  is  passed,  contributing  greater  stability.  The 
upright  should  be  made  of  one-inch  quadrilateral  machine  steel.  If  the 
child  is  not  to  walk  in  the  splint,  a  piece  of  quadrilateral  steel,  three- 
eighths  of  an  inch  in  diameter,  may  be  used. 


622 


ORTHOPEDIC  SURGERY. 


(c)  Peste7'ior  Bands. — To  fasten  the  leg  to  the  splint,  two  or  three 
posterior  curved  bands  are  necessary.  In  young  children  two  are  suffi- 
cient ;  in  older  children  and  adults  three  are  necessary.  If  two  bands 
are  used,  one  should  be  placed  below  the  middle  of  the  thigh  and  the 
other  at  the  upper  third  of  the  calf.  If  three  bands  are  used,  one  is 
placed  above  the  middle  of  the  thigh,  one  at  the  lower  part  of  the  thigh, 
and  one  at  the  upper  third  of  the  calf.  The  circumference  of  these 
bands  should  be  half  the  circumference  of  the  thigh  or  leg  at  a  corre- 
sponding level.     The  curve  should  form  the  posterior  half  of  a  circle 


Fig  557. 


-Apparatus  for  Extension.     (Fiske 
Prize  Fund  Essay.) 


Fig.  558.— Windlass  and  Ratchet  Appliance 
for  Extension.    (Fiske  Prize  Fund  Essay.) 


and  should  be  made  of  sheet  steel  of  No.  14  gauge  and  one  inch  wide. 
They  are  fastened  to  the  inner  side  of  the  upright  and  should  project 
one-half  of  an  inch  beyond  the  anterior  edge  of  the  upright.  By  means 
of  an  arrangement  similar  to  that  described  for  fastening  the  pelvic 
band  to  the  upright  in  heavy  patients,  these  are  fastened  to  the  upright, 
except  that  no  rivet  is  passed  through  the  upright  and  that  screws  in- 
stead of  rivets  are  used  to  fasten  the  two  ends  of  the  encircling  piece 
of  steel  to  the  calf  or  thigh  band.  By  tightening  these  screws  the 
curved  band  is  fastened  firmly  in  place,  and  by  loosening  the  screws  it 
can  be  moved  up  and  down  on  the  upright. 


PRACTICAL   DETAILS    OF  APPARATUS. 


623 


The  calf  bands  are  padded  on  the  anterior  surface  with  felt  and  cov- 
ered with  calf  or  ooze  leather  stitched  on  the  edges.  On  the  inner  end 
of  each  curved  band  a  webbing  strap  is  riveted,  to  pass  around  the  front 
of  the  leg  and  fasten  into  a  buckle,  riveted  on  the  end  of  the  calf  or  leg 
band  close  to  the  splint. 

Perineal  Bajids. — Perineal  bands  are  made  of  webbing  padded  in 
their  middle  half  by  felt  covered  with  canton  flannel,  or  they  are  made 
of  leather  padded  with  felt  and  covered  with  moose  hide.  The  cover- 
ing of  the  perineal  bands  should  be  stitched  together  on  the  under  side 
of  the  strap,  so  that  the  stitching  will  not  come  in  contact  with  the  skin 
of  the  perineum  where  pressure  would  make  it  uncomfortable. 

II.  CONVALESCENT    HIP    SPLINT. 

The  traction  hip  splint  may  be  changed  to  a  protection  splint  suita- 
ble for  use  in  convalescence  as  follows :  Instead  of  ending  below  in  the 
traction  foot-piece  described  above,  the  upright  is  cut  three  inches 
above  the  lower  end,  and  there  is  welded  to  the  upright  a  piece  long 
enough  to  extend  two  inches  below  the  sole  of  the  foot,  which  below  is 


o)i 


Fig.  559.— Detail  of  Foot-piece  of  Convalescent  Hip  Splint. 


expanded  into  a  bulbous  tip,  three-quarters  of  an  inch  in  diameter,  con- 
taining in  its  centre  a  hole,  in  which  is  inserted  a  plug  of  rubber,  which 
is  fastened  into  the  bottom  of  the  foot-piece. 

This  crutch  tip  serves  to  receive  the  irnpact  of  the  weight  in  walk- 
ing, and  should  be  of  such  a  length  that,  while  the  ball  of  the  foot  may 
be  used  in  \valking,  the  heel  is  prevented  from  touching  the  ground. 
The  length  of  the  upright  under  these  conditions  should  be  the  dis- 
tance from  the  anterior  superior  spine  of  the  ilium  to  the  bottom  of  the 
heel  of  the  shoe,  when  the  foot  is  at  a  right  angle,  plus  one  to  one  and 
one-half  inches.  In  case  it  is  desired  to  have  the  splint  made  so  that 
its  length  may  be  adjusted  to  the  growth  of  the  child,  this  may  be  done 


624 


ORTHOPEDIC  SURGERY 


by  cutting  off  the  lower  end  of  the  upright  at  a  distance  of  three  inches 
from  its  normal  length.  This  part  is  then  forged  flat  on  its  outer  sur- 
face for  a  distance  of  three  and  a  half  inches,  and  is  rounded  on  its  inner 
and  threaded  for  screws  by  holes  one-half  of  an  inch  apart. 

The  part  of  the  upright  carrying  the  foot-piece  is  flattened  at  its 
upper  two-thirds  and  lies  on  the  outside  of  the  lower  part  of  the  up- 
right. 

The  end  of  the  lower  piece  is  drawn  out  to  form  two  clips  curving 
inward,  which  embrace  between  them  the  lower  end  of  the  upright, 
three  and  one-half  inches  above 
where  it  is  cut  off.  Holes  are  drilled 
in  both  uprights  and  threaded  for 


Fig.  560. — Convalescet:t  Hip  Splint. 
(See  Figs.  128  and  129.) 


Fig.  561.  — Modified  Hip  Splint. 
Fig.  123  ) 


(Dane.)     (See 


screws  one-quarter  of  an  inch  in  diameter.  By  means  of  screws  pass- 
ing through  these  holes,  the  extension  piece  may  be  fastened  to  the 
upright  at  any  desired  level. 

In  the  case  of  adults  and  older  children,  it  is  desirable  that  the  con- 
valescent splint  should  be  jointed  at  the  knee.  This  joint  should  be 
situated  opposite  the  inner  condyle  of  the  femur.  Of  the  various  forms 
of  joint  in  use  those  shown  in  the  diagrams  will  be  most  serviceable. 
The  illustrations  will  show  their  construction. 


PRACTICAL   DETAILS    OF  APPARATUS.  625 

12.    THE    DOUBLE    UPRIGHT    HIP    SPLINT.' 

The  special  object  of  this  form  of  hip  sphnt  is  to  furnish  a  firmer 
grasp  upon  the  pelvis,  and,  when  converted  to  the  convalescent  type, 
to  transfer  the  support  in  walking  to  a  point  nearer  the  median  line  of 
the  body.  Its  lower  portion  is  similar  to  the  Thomas  knee  splint,  with 
the  exception  that  the  outer  upright  is  made  somewhat  heavier  and  is 
prolonged  above  the  ring  for  about  one  inch.  The  lower  ends  of  the 
uprights  are  also  furnished  with  some  device  for  making  traction,  either 
in  the  form  of  a  windlass  or  simply  a  pair  of  buckles.  The  pelvic  por- 
tion of  the  splint  is  similar  to  that  of  the  long  traction  hip  splint,  with 
the  addition  of  a  second  posterior  pelvic  arm.  The  lower  pelvic  arm  is 
carried  as  far  down  as  possible  over  the  sacrum ;  the  upper  follows 
closely  under  the  curve  made  by  the  crests  of  the  ilia.  Each  of  these 
arms  is  prolonged  around  the  opposite  or  sound  side  of  the  pelvis  by 
means  of  a  strip  of  No.  20  gauge  steel,  one-sixteenth  of  an  inch  thick, 
riveted  to  its  free  extremity.  To  these  in  turn  are  riveted  the  outer 
ends  of  the  webbing  straps,  which  complete  the  circuit  by  passing 
through  two  buckles,  one  at  the  extremity,  the  second  three  inches  far- 
ther along  on  the  single  rigid  anterior  arm.  The  padding  consists  of  a 
thick  piece  of  leather,  a  little  wider  than  the  pelvic  arms,  riveted  firmly 
on  the  inside  to  them  and  their  flexible  extensions.  This  leather  is 
free  only  as  a  flap  under  the  space  occupied  by  the  straps  and  buckles. 
The  single  perineal  strap,  which  passes  through  the  groin  on  the  sound 
side,  is  made  of  "window-chain  "  padded  with  felt,  riveted  to  the  lower 
pelvic  arm  behind  and  hooking  over  a  bent  staple  riveted  near  the  outer 
extremity  of  the  anterior  arm. 

13.     THOMAS    HIP    SPLINT. 

The  Thomas  hip  splint  consists  of:  {a)  an  upright;  ib')  a  chest 
band;  {c)  a  thigh  band;  and  {d)  a  calf  band. 

{a)  The  upright  runs  vertically  at  one  side  of  the  patient's  back  and 
follows  the  line  of  the  diseased  leg.  It  reaches  from  the  lower  angle  of 
the  scapula  to  the  junction  of  the  middle  and  lower  third  of  the  leg, 
passing  posteriorly  to  the  hip-joint.  It  is  bent  in  two  places — one  op- 
posite the  fold  of  the  buttock,  and  the  other  just  above  the  hip-joint, 
so  that  the  leg  portion  and  body  portion  follow  parallel  lines,  distant 
from  each  other  from  one-half  to  two  inches,  the  leg-piece  lying  in  a 
plane  somewhat  anterior  to  the  body-piece.  The  bends  should  be 
round  rather  than  angular.  From  the  fold  of  the  buttock  to  the  lower 
end  of  the  spine  the  leg  portion  is  perfectly  straight,  as  is  also  the  upper 
portion  of  the  splint  from  the  bend  opposite  the  joint  to  its  upper  end. 

'John  Dane:  Trans.  Am.  Orth.  Assn.,  x.,  233;  xiv.,  74. 
40 


626 


ORTHOPEDIC  SURGERY. 


The  upright  is  usually  twisted  somewhat  in  its  longitudinal  axis,  so  that 
the  body  portion  lies  slightly  to  the  side  and  flat  against  the  curved  out- 
line of  the  chest,  while  the  leg  portion  lies  directly  posterior  to  the 
middle  line  of  the  leg.  The  buttock  bend  lies  between  the  gieat  tro- 
chanter and  the  tuberosity  of  the  ischium.  The  upright  for  a  child  of 
ten  should  measure  three-quarters  to  three-sixteenths  of  an  inch,  and 
is  made  of  the  softest  and  toughest  iron  available.  Annealed  steel  is 
not  the  material  to  use. 

{b)  The  chest-piece  is  made  of  flat  bar  iron,  which  varies  in  width 
and  thickness  in  proportion  to  the  patient.     It  should  be  long  enough 

to  encircle  the  chest,  leaving  a  gap  be- 
tween its  ends  of  one  or  two  inches.  It 
is  joined  to  the  uprights  at  a  distance  of 
one  or  two  inches  to  the  side  of  its  middle 
point,  the  shorter  wing  encircling  the  chest 
on  the  side  of  the  disease.  The  relative 
leng-th  of  the  two  winsfs  of 


the  chest-piece  may  be  de- 
termined by  measuring  from 
the  low^er  angle  of  the  scapula 
on  the  diseased  side  round 
each  side  of  the  chest  to  the 
point  in  front  where  it  is  in- 
tended that  the  piece  should 
terminate.  The  upper  end 
of  the  main  upright  is  forged 
flat  and  bent  over  the  chest- 
piece,  and  the  two  are  made 
fast  by  a  single  rivet.  In 
each  end  of  the  chest-piece, 
which  is  flattened  for  the 
purpose,  a  hole,  three-quar- 
ters of  an  inch  in  diameter,  is 
drilled  for  the  fastening  of 
the  shoulder  bandage.  The 
chest-piece  and  the  upright 
form  a  right  angle  with  each 
other. 

(r)  The  thigh  band  is 
made  of  flat  bar  iron  of  about 
the  same  size  as  the  upright,  and  is  fastened  to  the  inner  surface  of 
the  upright  by  one  rivet,  at  a  point  about  one  inch  below  the  lower 
bend  of  the  upright.  The  thigh  band  should  be  riveted  to  the  upright 
so  that  its  inner  portion  is  one  inch  or  more  longer  than  the  outer. 


Fig.  ,62. 


sm 


Fig.  563 


Fig. 


562.— Thomas  Hip  Splint  Covered  and  Provided 
with  Straps. 
Fig.  563.— Diagrammatic  Outline.    Paralleli&m  of  body 
and  leg  portions.     (Ridlon.) 


PRACTICAL   DETAILS   OF  APPARATUS. 


627 


{d)  The  calf  band  is  made  of  flat  bar  iron,  and  is  joined  to  the 
lower  end  of  the  upright  by  a  single  rivet  in  the  same  manner  and  in 
the  same  relative  position  as  the  thigh  band.  The  inner  surface  of  the 
splint  next  to  the  patient  is  covered  with  harness-makers'  felt  or  ordi- 
nary boiler  felting,  about  one-quarter  of  an  inch  in  thickness.  The 
whole  is  then  covered  with  basil  leather,  a  variety 
of  sheep-skin,  which  is  put  on  wet  and  snugly  stitched 
into  place.  This  shrmks  when  it  dries,  which  will 
prevent  any  slipping  of  the  cover  of  the  splint. 

The  final  adjustment  of  the 
splint  is  made  by  means  of 
wrenches  until  the  bands  fit 
closely  to  the  leg  and  chest. 
Another  piece  of  bandage  is 
wound  around  the  splint  and 
leg  at  its  lower  extremity,  and 
pinned  securely  to  an  anterior 
piece  wound  around  the  thigh 
above  the  knee.  Shoulder- 
straps  pass  from  the  top  of  the 
upright  over  the  shoulders  to 
the  anterior  ends  of  the  splint.' 


14.  THOMAS  KNEE  SPLINT. 

The  Thomas  knee  splint 
consists  of:  (<:?) a  perineal  ring; 
(If)  two  uprights ;  and  (r)  a  bot- 
tom plate.  FIG.  564.  Fig.  565. 

{a)     The     ring     is      made     of     fig.  564.-Thomas  Hip   Splint,  DouWe.     (Ridlon.) 

round  steel  wire,  one-quarter  of  ^'°-  565-Thomas  Knee  spiint  with  R,ng  covered 

'  ^  and  Posterior  Leather  Attached. 

an  inch  in  diameter  for  a  child 

of  ten  years,  increasing  to  one-half  of  an  inch  for  use  in  adults.  The 
ring  is  an  irregular  ovoid,  flattened  in  front  and  turned  out  at  the 
posterior  and  inner  portion  of  the  thigh.  It  slopes  from  without  in- 
ward and  from  before  backward.  It  is  fastened  to  the  inner  upright 
at  an  angle  of  one  hundred  and  thirty-five  degrees,  and  in  the  anterior 
plane  the  ring  forms  with  the  inner  bar  an  angle  of  about  one  hundred 
and  forty-five  degrees.  In  making  the  ring  the  ends  should  be  joined 
by  welding  in  preference  to  brazing.  The  anterior  surface  of  the  ring 
is  made  flat  on  account  of  the  flatness  of  the  groin,  its  posterior  part  is 
expanded  to  accommodate  the  thickness  of  the  buttock,  and  the  antero- 
posterior tilt  is  to  enable  the  patient  to  rest  comfortably  on  the  ring 

'  Ridlon  and  Jones  :  "  Chronic  Joint  Disease,"  p.  106.  1S94. 


62  8 


ORTHOPEDIC  SURGERY. 


with  the  tuberosity  of  the  ischium.  The  measurement  of  the  ring  is 
the  oblique  circumference  of  tiie  thigh  taken  as  high  up  as  possible  at 
an  angle  of  about  one  hundred  and  thirty-five  degrees  to  the  long  axis 
of  the  leg.  To  this  measure  an  inch  is  added  to  allow  for  the  padding. 
{b')  The  iiprigJits  are  made  of  five-sixteenth  steel  wire.  The  inner 
bar  is  welded  to  the  upright  at  the  angle  mentioned.  The  other  rod  is 
fastened  to  the  ring  slightly  farther  back  than  the  outer  rod.  The  bot- 
tom of  the  rod  should  come  two  inches  below  the  sole  of  the  bare  foot. 


Fig.  566.— Side  View  of  Ring  of  Thomas  Knee  Splint  Uncovered  and  Covered,  Showing 
Proper  Shape.     (Drawn  from  Ridlon  and  Jones.) 

As  originally  made  by  Mr.  Thomas,  the  splint  simply  terminated  in  a 
loop  where  the  inside  upright  was  bent  round  below  the  foot  to  return 
as  the  outside  upright. 

{f)  The  Bottom  Plate. — For  use  in  walking,  however,  some  form  of 
foot  plate  is  necessary.  For  the  more  acute  cases  it  is  convenient  to 
weld  to  the  bottom  of  the  uprights  a  base  plate  or  patten,  oval  or  round 
in  shape,  three  inches  in  diameter,  with  a  hole  one  and  one-half  inches 
in  diameter  in  its  centre.  This  is  made  of  an  ordinary  iron  washer, 
one-quarter  of  an  inch  in  thickness.  It  should  be  perforated  by  two  or 
more  holes,  in  order  that  a  piece  of  leather  may  be  riveted  to  the  under 
side  for  walking.' 

Measurement . — The  length  of  the  inner  upright  is  the  distance  from 
the  tuberosity  of  the  ischium  to  the  sole  of  the  foot  plus  two  or  more 

'At  the  Hospital  for  the  Ruptured  and  Crippled  in  New  York  there  is  in  use 
an  arrangement  for  protecting  the  bottom  of  the  splint  in  which  the  uprights  termi- 
nate below  in  a  cross  bar,  which  is  put  through  a  section  of  rubber  carriage  tire, 
forming  an  efficient  and  inexpensive  foot-piece. 


PRACTICAL  DETAILS   OF  APPARATUS. 


629 


inches.     The  required  width  at  the  knee  and  ankle  should  be  given  in 
order  that  the  bars  may  clear  the  side  of  the  limb. 

Padding. — The  ring  is  padded  with  boiler  felting  for  a  thickness  of 
about  one-half  of  an  inch  on  its  outer  portion  and  from  one  to  one  and 
one-half  inches  in  thickness  on  its  inner  posterior  portion.  This  is 
then  covered  with  basil  feather  or  a  tanned  sheep-skin  put  on  wet  and 
sewed  after  the  manner  of  the  harness-maker  along  the  lower  and  outer 
border  of  the  ring,  where  the  seam  will  not  chafe  the  patient.'  Two 
strips  of  basil  leather,  about  three 
inches  in  width,  are  sewed  at  one 
end  round  one  of  the  side  bars, 
the  other  end  being  left  free  and 
of  sufficient  length  to  be  drawn 
across  to  the  opposite  bar,  and 
when  srewed  there  to  form  a  sup- 
port for  the  back  of  the  limb 
when  the  splint  is  applied.  One 
of  these  straps  is  to  be  placed  at 
the  back  of  the  knee,  or  above  it 
if  the  knee  is  too  sensitive,  and 
the  other  at  the  back  of  the 
ankle.  When  the  splint  is  ap- 
plied the  leg  is  fastened  to  it  by 
means  of  a  roller  bandage  carried 
to  and  fro  around  the  upright 
and  fastening  in  front  of  the  leg  just  above  the  knee,  where  it  passes 
over  a  thick  pad  of  metal  or  of  leather  placed  in  front  of  the  lower  end 
of  the  thigh.  A  roll  of  bandage  is  also  fastened  in  the  same  manner 
over  an  anterior  pad  placed  in  front  just  below  the  knee. 


Fig.  567.— View  of  Front  and  Back  of  Ring  of 
Thomas  Knee  Splint  Covered,  Showing  De- 
pression at  Back  for  Tuberosity  of  Ischium. 
(Drawn  from  Ridlonand  Jones.) 


15.   THOMAS   CALIPER  SPLINT. 

In  cases  which  are  not  sufficiently  acute  to  require  the  use  of  the 
plate  attached  below  the  foot,  the  lower  ends  of  the  inner  and  upper 
bars  may  be  turned  sharply  inward  at  a  right  angle  at  a  point  one  inch 
below  the  bottom  of  the  heel  of  the  boot."  The  measurement  for  this 
may  be  taken  by  applying  the  unfinished  splint  in  its  proper  relation 
and  marking  on  the  upright  the  place  where  the  bend  should  occur,  or 
the  distance  may  be  measured  from  the  tuberosity  of  the  ischium  to  a 
point  one  inch  below  the  bottom  of  the  sole  of  the  boot.  The  splint  is 
then  fastened  to  the  boot  by  means  of  a  hole  drilled  through  the  heel 
from  side  to  side,  into  which  a  steel  tube  is  inserted,  of  a  proper  calibre 

'  Ridlon  and  Jones  :  "  Chronic  Joint  Disease,"  Chicago,  1894. 
^  See  Fig.  577  for  detail  of  foot-piece. 


630  ORTHOPEDIC  SURGERY. 

to  accommodate  the  ends  of  the  splint.  The  bends  in  the  ends  of  the 
sphnt,  which  should  each  be  three-quarters  of  an  inch  long,  are  passed 
into  this  tube  and  are  held  together  by  the  leather  straps  above  men- 
tioned. In  the  use  of  this  splint  a  triangular  piece  should  be  cut  away 
from  the  back  of  the  shoe  and  a  loose  piece  of  leather  sewed  on  over  it. 
This  triangle,  with  its  apex  upward,  should  begin  well  above  the  coun- 
ter of  the  shoe,  and  at  its  base  should  be  as  wide  as  the  width  of  the 
heel.  In  this  way  excoriation  of  the  heel  can  be  avoided.  The  splint 
may  be  finished  by  being  blued  or  japanned. 

16.    JOINTED   KNEE    SPLINT. 

T^s  apparatus  consists  of  {a)  two  uprights ;  {b)  an  arm  for  perineal 
band;  {c)  a  foot-piece;  and  {d)  two  posterior  bands  for  the  thigh  and 
one  for  the  calf. 

It  is  intended  to  serve  as  an  apparatus  for  fixing  the  knee  at  any 
angle  and  for  making  traction  upon  it  if  desired.  It  also  furnishes  pro- 
tection from  weight-bearing  in  walking. 

(^7)  Uprights. — The  outside  upright  reaches  from  the  level  of  the 
trochanter  at  the  top  to  two  and  one-half  inches  below  the  sole  of  the 
bare  foot  below.  It  is  constructed  of  flat  machine  steel,  five-eighths  of 
an  inch  thick.  The  outside  is  constructed  in  two  parts,  which  are 
joined  together  opposite  the  inner  condyle  of  the  femur  to  make  a 
joint.  This  joint  may  be  left  movable  or  may  be  fastened  at  any  angle. 
The  two  ends  of  the  upright  which  form  this  joint  are  flattened  into 
discs,  the  centre  of  which  is  drilled  for  a  hole  for  the  formation  of  the 
joint.  The  two  discs  where  they  come  in  contact  are  ground  fiat,  and  a 
disc  of  fiat  steel,  two  inches  in  diameter,  is  placed  over  the  inner  sur- 
face of  the  joint.  Through  a  hole  drilled  in  its  centre  a  rivet  is  passed 
binding  the  three  pieces  together,  forming  an  antero-posterior  joint. 
This  joint  should  lie  somewhat  back  of  the  plane  of  the  uprights,  and 
for  this  purpose  the  ends  of  the  uprights  which  are  to  form  the  joint 
are  bent  back  on  the  flat  about  one  and  one-half  inches.  This  joint  is 
set  at  any  desired  angle  by  means  of  a  set  screw  passing  through  the 
upper  end  of  the  lower  half  of  the  upright,  passing  into  holes  drilled  in 
the  steel  disc  one-half  of  an  inch  apart.  This  plate  should  be  oblong 
in  shape,  about  two  inches  wide  and  three  or  four  inches  in  length. 

The  inner  upright  runs  on  the  inside  of  the  leg  from  a  point  one  or 
two  inches  below  the  perineum  to  the  bottom  piece.  It  is  lighter  than 
the  outside  upright,  and  the  two  pieces  of  the  upper  and  lower  parts  are 
joined  together  opposite  the  inner  condyle  of  the  femur  by  a  simple 
antero-posterior  joint. 

{h)  The  arm  for  the  perineal  bands  consists  of  an  anterior  portion, 
a  vertical  portion,  and  a  horizontal  posterior  portion  curved  to  fit  the 


PRACTICAL  DETAILS    OF  APPARATUS. 


631 


km^nl*^ 


pelvis.  The  anterior  arm  reaches  from  the  top  of  the  upright,  curving 
forward  and  sHghtly  downward  to  a  point  just  inside  the  origin  of  the 
adductor  tendons.  The  vertical  portion  of  the  perineal  arm  rises  in  the 
line  of  the  upright  to  just  below  the  level  of  the  posterior  superior  spine 
of  the  ilium.  It  then  turns  at  a  right  angle  back- 
ward, and  runs,  following  the  cur\e  of  the  pelvis, 
to  a  point  just  below  the  posterior  superior  spine  of 
the  ilium.  This  arm  is  drilled  at  its  front  and  back 
ends  with  holes,  to  which  are  fastened  buckles  to 
carry  the  perineal  band.  The  perineal  arm  should 
be  made  of  cast  steel,  five -eighths  of  an  inch  wide 
and  one-quarter  of  an  inch  thick.  The  horizontal 
part  of  the  perineal  arm  is  curved  to  fit  the  outside 
of  the  upright  where  it  crosses  it  and  is  riveted  to 
it.  A  steel  pad,  shaped  to  fit  the 
contour  of  the  hip,  is  placed  inside 
of  the  upper  end  of  the  outside  up- 
right. This  plate  should  be  oblong 
in  shape,  about  two  inches  wide  and 
three  or  four  inches  in  length. 

(r)  The  Foot-Piece. — ^The  foot- 
piece  of  the  splint,  which  connects 
with  the  outside  and  inside  uprights 
or  as  a  continuation  of  them,  is  fur- 
nished with  the  windlass  traction  ap- 
paratus described  in  speaking  of  the 
traction  hip  splint.  This  should 
come  at  a  point  one  and  one-half 
inches  below  the  shank  of  the  boot. 

{d)  The  posterior  bands  are  two 
in  number,  both  semicircular  in  shape 
and  convex  backward  to  follow  the 
contour  of  the  leg  and  thigh.  The 
of  the  thigh  is 
upper  end,  and 
outer  upright  is 


Fig.  56S. 
Fig.  568.  — Application 

Length     of 

(Burrell.) 
Fig.  569. —  Splint  for  Traction  on  Knee 

any  Angle. 


Fig.  569. 

for    Adjusting    the 
rhomas    Knee    Splint. 


arm   passing  back 

broadened    at    its 

where  it  joins  the 

from  one  to  two  inches  higher  than 

where  it  joins  the  inner  upright.     It 

is  fastened  by  rivets  to  the  top  of 

both  uprights,  and  its  upper  edge  should  follow  the  line  of  the  gluteal 

fold  and  should  be  well  below  it.     This  thigh-piece  should  be  two  inches 

wide  at  its  inner  end  and  three  inches  wide  at  its  outer  end,  and  should 

be  made  of  No.  15  gauge  sheet  steel.     The  posterior  calf  band  should 

encircle  the  calf  at  its  upper  third,  being  curved  to  fit  it,  and  fastened 


632  ORTHOPEDIC  SURGERY. 

to  the  inside  of  both  uprights  at  the  proper  point.     It  should  be  one 
inch  in  width. 

Buckles  should  be  fastened  by  rivets  to  the  upper  end  of  the  inner 
upright  and  at  a  corresponding  point  on  the  outer  upright  to  make 
upward  traction  if  desired.  Lacings  of  stout  sole  leather  are  fastened 
to  the  upright,  lacing  in  front  to  encircle  and  steady  the  thigh  and 
calf.     They  are  furnished  with  studs  for  lacing,  half  an  inch  apart. 

When  the  disease  has  become  convalescent  a  movable  joint,  which 
can  be  stopped  at  any  angle  by  a  pin  in  the  disc,  may  be  substituted  for 
the  fixed  joint,  so  that  the  patient  can  bend  the  knee  in  sitting.  This 
type  of  joint  has  been  described  in  speaking  of  the  convalescent  hip 
sphnt.  At  this  stage  also  the  traction  arrangement  of  the  foot-piece 
may  be  removed  and  the  splint  used  as  a  protection  splint,  which  can 
be  bent  at  the  knee  when  desired.  In  this  case  it  is  fastened  to  the 
boot  in  a  manner  similar  to  that  described  for  the  convalescent  hip 
splint. 

17.   FIXATION    ANKLE    SPLINT. 

In  cases  convalescent  from  ankle-joint  disease,  in  which  it  is  desired 
to  prevent  motion  but  which  are  sufficiently  recovered  to  bear  weight, 
a  simple  fixation  splint  may  be  substituted  for  the  plaster-of-Paris  band- 
age. This  consists  of  {a)  two  uprights;  {b)  afoot-piece;  and  (<:)  a 
posterior  calf  band. 

{a)  The  tiprights  run  on  the  inside  and  on  the  outside  of  the  leg 
from  the  bottom  of  the  foot-piece  to  a  point  one  inch  below  the  tubercle 
of  the  tibia.  They  should  be  curved  to  fit  the  outline  of  the  leg,  but 
should  be  bent  out  so  as  not  to  touch  the  malleoli.  They  should  be 
made  of  No.  10  gauge  machine  steel,  one-half  of  an  inch  wide.  One 
continuous  piece  of  steel  may  be  used,  passing  down  the  leg  as  the 
outside  upright,  being  bent  at  a  right  angle  to  pass  under  the  foot-piece 
and  being  turned  up  opposite  the  inner  border  of  the  foot-piece,  to  re- 
turn up  the  leg  as  the  inside  upright. 

{]))  ThQ  foot-piece  consists  of  a  plate  of  cast  steel,  one-quarter  of  an 
inch  thick,  forged  to  the  shape  of  the  sole  of  the  foot,  extending  in 
front  to  just  behind  the  cleft  between  the  toes  and  the  foot.  On  the 
side  it  should  be  one-quarter  of  an  inch  narrower  on  each  side  than  the 
whole  width  of  the  foot,  and  it  should  stop  one-half  of  an  inch  in  front 
of  the  back  part  of  the  os  calcis.  It  should  be  curved  to  fit  approxi- 
mately the  sole  of  the  foot,  and  its  inner  surface  should  be  slightly 
higher  than  the  outer  surface.  It  should  be  riveted  to  the  piece  of 
steel  connecting  the  two  uprights,  passing  across  on  its  under  surface 
at  a  point  below  the  malleoli. 

{c)  ThQ posterior  calf  ba7id  ]om?,  the  two  upper  ends  of  the  upright, 
and  is  curved  backward  to  fit  the  posterior  surface  of  the  calf.     It  con- 


PRACTICAL  DETAILS   OF  APPARATUS.  633 

sists  of  a  piece  of  steel,  one  and  one-eighth  inches  wide  and  No.  15 
gauge,  and  is  riveted  to  the  upper  inner  surface  of  the  two  uprights. 
This  band  is  padded  with  felt  and  covered  with  leather.  A  cuff  of 
stout  leather  is  riveted  to  the  upright,  following  the  contour  of  the  calf 
and  lacing  in  front.  A  piece  of  softer  leather,  cut  like  the  upper  of  a 
low  shoe,  ending  in  front  behind  the  metatarso-phalangeal  joint  of  the 
great  toe  and  with  the  part  over  the  point  of  the  heel  cut  away,  is  riv- 
eted by  its  under  surface  to  the  sole  plate,  to  pass  over  the  top  of  the 
foot,  and  laces  down  the  middle  line.  It  should  be  protected  by  a  fly 
covering  the  junction  of  the  two  pieces,  sewed  to  the  inner  side  of  one 
of  them,  and  the  edges  of  the  leather  pieces  coming  over  the  dorsum 
of  the  foot  should  be  perforated  for  eyelets  one-half  of  an  inch  apart. 
The  posterior  part  of  this  foot  lacing  should  be  split  in  the  vertical  line 
behind  and  shortened  sufficiently  to  set  snugly  back  of  the  heel. 

18.    KNOCK-KNEE    BRACE. 

Measurements  for  knock-knee  braces  are  given  for  a  child  of  about 
the  age  of  three. 

Knock-knee  braces  consist  of  three  parts :  {a)  an  upright ;  {b')  a 
foot-piece;  and  {c)  two  posterior  bands. 

{ci)  The  upright  is  made  of  cast  steel,  five-eighths  of  an  inch  wide 
and  one-eighth  of  an  inch  thick,  and  runs  along  the  outer  side  of  the 
leg  from  a  point  opposite  the  ankle-joint  to  a  point  one-half  of  an  inch 
above  the  trochanter.  The  top  of  the  upright  from  this  point  curves 
backward  to  a  point  just  below  the  posterior  superior  spine  of  the  ilium, 
following  the  contour  of  the  buttock.  The  angle  of  the  curve  at  the 
top  of  the  upright  is,  of  course,  determined  by  the  relative  position  of 
the  two  points  given.  The  bottom  part  of  the  upright  is  flattened  and 
enlarged,  and  its  centre  bored  with  a  hole,  one-quarter  of  an  inch  in 
diameter,  through  which  is  to  pass  the  spindle  of  the  ankle-joint. 

{b')^\iQ.  foot-piece  Q.o\\^\^\.^  of  a  triangular  piece  of  steel,  nearly  as 
wide  as  the  boot  at  its  back,  and  at  the  apex  which  comes  in  front  it 
terminates  in  a  rounded  point.  It  should  be  approximately  one  and  one- 
half  inches  long,  and  should  be  made  of  machine  steel,  one-quarter  of  an 
inch  thick.  It  is  fastened  to  the  inside  of  the  bottom  of  the  boot  by 
rivets,  and  from  its  inner  border  just  below  the  upper  malleolus  there 
runs  up  from  it  a  vertical  arm  of  about  the  same  size  and  width  as  the 
upright,  to  join  the  upright  opposite  the  ankle-joint.  It  is  curved  so  as 
to  clear  the  outer  border  of  the  foot,  and  is  joined  to  the  bottom  of  the 
outside  upright  opposite  the  malleolus  as  a  free  joint  moving  in  the 
antero-posterior  plane.  The  inner  surface  of  this  joint  lying  next  to 
the  malleolus  should  be  furnished  with  a  circular  pad  of  steel,  about 
the  size  of  a  twenty-five-cent  piece,  padded  with  felt  and  covered  with 


634 


ORTHOPEDIC  SURGERY. 


leather  to  protect  the  outer  malleoh;s  from  pressure.  The  top  of  the 
upright,  where  it  bears  on  the  side  of  the  thigh,  is  furnished  with  a 
small  pad. 

(<:)  There  should  be  riveted  to  the  inner  side  of  the  upright  two 
semicircular  posterior  bands,  curved  posteriorly,  made  of  sheet  steel, 
two  inches  wide.  No.  17  gauge,  which  should  cross  the  lower  third  of 
the  thigh  and  the  upper  third  of  the  calf.  These  points  are  connected 
by  a  strip  of  steel  running  from  the  middle  of  the  upper  one  to  the 

middle  of  the  lower  one  in  a  vertical  line. 
This  steel  should  be  one-half  of  an  inch 
wide  and  one-eighth  of  an  inch  thick,  and 
should  be  fastened  to  the  posterior  sur- 
faces of  the  thigh  and  calf  bands. 

There  should  be  a  buckle  at  the  pos- 
terior end  of  the  curved  portion  of  the 
upright  and  another  buckle  on  each  side 
where  the  upright  begins  to  bend  upward 
and  backward.  The  posterior  buckles 
should  be  connected  by  a  strap  running 
behind  the  body,  and  the  anterior  buckles 
by  a  strap  running  in  front.  By  tighten- 
ing or  loosening  these  straps,  in  connec- 
tion with  the  curve  of  the  posterior  arms, 
any  degree  of  inversion  or  eversion  of  the 
foot  may  be  secured  in  walking.  Bend- 
ing the  band  outward  and  loosening  the 
posterior  strap  secures  eversion,  and 
bending  the  bands  inward  and  tightening 
the  anterior  strap  secures  inversion. 
The  tops  of  the  uprights  where  they  lie 
in  contact  with  the  patient  should  be 
padded  with  felt  covered  with  soft  leather. 
The  knee  is  pulled  outward  to  the  upright  by  a  square  or  oblong  pad  of 
leather  lined  with  sheepskin.  This  pad  should  cover  the  inner  surface 
of  the  knee,  and  should  be  about  four  inches  long  by  three  inches  wide. 
To  the  upper  and  lower  corner  and  to  the  middle  on  each  side  are  sewed 
leather  straps  running  sideways,  the  anterior  ones  passing  in  front  of 
the  leg  and  the  posterior  behind  the  leg,  to  fasten  into  leather  buckles, 
one-half  of  an  inch  wide,  riveted  by  leather  tags  to  three  buckles  on  the 
outside  of  the  upright — one  at  a  point  opposite  the  knee,  and  one  at 
a  point  two  inches  above,  and  one  two  inches  below  the  knee.  There 
are  two  buckles  at  each  level,  one  facing  forward  and  the  other  back- 
ward.    The  splint  is  finished  by  being  blued  or  japanned - 

Instead  of  finishing  the  top  of  the  upright  by  bending  it  backward, 


Fig.  570. — Knock-knee  Brace. 


PRACTICAL   DETAILS   OF  APPARATUS.  635 

it  may  be  finished  by  being  joined  to  a  curved  band  lying  transversely 
along  the  side  of  the  pelvis.  The  upright  is  made  as  if  it  were  to  be 
curved  upward  and  backward  and  carried  to  the  height  where  the  beixl 
begins.  It  is  then  flattened  and  its  centre  drilled  for  the  formation  of 
a  joint.  A  band  to  lie  against  the  side  of  the  pelvis,  one  inch  above  the 
level  of  the  trochanter,  is  then  made  of  sheet  steel,  one  inch  wide,  No. 
14  gauge,  and  in  length  reaching  from  just  behind  the  anterior  superior 
spine  to  the  posterior  superior  spine  of  the  ilium.  This  band  is  curved 
to  fit  the  pelvic  outline,  and  is  padded  with  felt  and  covered  with 
leather.  At  a  point  vertically  over  the  trochanter  is  riveted  to  its  out- 
side a  piece  of  steel  of  the  same  material,  flattened  at  its  lower  end  to 
make  with  the  top  of  the  upright  an  antero-posterior  joint  opposite  the 
trochanter.  The  front  and  back  ends  of  this  pelvic  band  are  furnished 
with  buckles  to  carry  anterior  and  posterior  straps.  The  apparatus  is 
slightly  less  unsightly  and  a  little  more  comfortable  in  older  children 
than  is  the  kind  first  described.  The  measurements  are  sufficiently 
well  defined  in  the  description  of  the  apparatus,  the  length  of  the  up- 
right being  the  distance  from  the  lower  part  of  the  sole  of  the  boot  to 
a  point  on  a  level  with  the  trochanter. 

19.    BOW-LEG    IRONS. 

Measurements  for  bow-leg  irons  are  given  for  a  child  of  about  the 
age  of  three.  They  are  similar  in  construction  to  the  knock-knee 
braces  just  described,  and  certain  details  of  construction  need  not  be 
repeated.  The  apparatus  consists  of  two  parts:  {a)  an  upright  and  {b') 
a  foot-piece. 

{a)  The  upright  runs  in  the  middle  of  the  inner  surface  of  the  leg 
from  a  point  opposite  the  inner  malleolus  to  a  point  an  inch  or  more 
below  the  origin  of  the  adductor  muscles.  At  this  point  the  upright 
curves  round  the  front  of  the  thigh  in  a  line  upward  and  outward 
to  a  point  just  posterior  to  the  trochanter.  This  anterior  arm  is 
convex  forward,  to  fit  the  curve  of  the  upper  part  of  the  thigh.  The 
upright  and  anterior  arm  are  made  of  one-half-inch  cast  steel,  one-six- 
teenth of  an  inch  thick.  It  is  jointed  below,  opposite  the  internal  mal- 
leolus, to  a  foot-piece  similar  to  that  described  in  knock-knee,  except 
that  the  arm  from  the  foot-piece  to  the  ankle-joint  runs  on  the  inner 
side  of  the  foot.  The  inner  surface  of  this  joint  should  be  protected  by 
a  pad  similar  to  that  described  in  the  knock-knee  apparatus.  The  up- 
per end  of  the  upright  is  padded  with  felt  and  covered  with  leather  to 
prevent  chafing  where  it  touches  the  skin ;  and  buckles,  two  on  each 
upright,  one  facing  forward  and  one  back,  are  fastened  on  the  top  of 
each  upright.  From  these  leather  or  webbing  straps  run,  one  in  front 
of  the  patient  and  one  behind  the  patient,  to  the  opposite  side.  In  the 
case  of  a  single  bow-leg  upright  these  straps  run  to  a  pad  of  leather  on 


636 


ORTHOPEDIC  SURGERY, 


the  opposite  trochanter,  which  serves  as  a  point  of  resistance  for  cor- 
rective pressure  on  the  leg.  In  the  apparatus  for  double  bow-legs  the 
upright  at  the  opposite  side  serves  to  furnish  resistance  instead  of  the 
pad.  In  double  bow-leg,  therefore,  one  strap  connects  the  uprights  in 
front  and  the  other  behind  the  body.  By  the  curve  of  the  arms  and  by 
tightening  of  the  anterior  or  posterior  strap  the  feet  and  legs  may  be 
inverted  or  everted,  as  in  the  knock-knee  braces. 

ill)  The  foot-piece  is  in  construction  similar  to  that  described  in 
knock-knee. 

Pressure  upon  the  curve  is  made  by  an  oblong  piece  of  leather,  sim- 
ilar to  that  described  in  knock-knee,  furnished  with  two  or  three  straps 


Fig.  571.— Bow-leg  Irons. 


Fig.  572. — Antero-Posterior  Bow-leg  Brace. 


at  its  front  and  back  border,  to  pass  in  front  of  and  behind  the  leg,  and 
fastening  into  buckles  upon  the  upright  at  appropriate  points.  This 
pad  should  embrace  the  entire  curve  of  the  leg. 

The  measurement  for  bow-leg  irons  is  sufficiently  described  in 
speaking  of  the  uprights.  The  length  is  along  the  inner  side  of  the 
leg  from  the  bottom  or  sole  of  the  shoe  to  a  point  one  inch  or  more  be- 
low the  origin  of  the  adductor  muscles.  The  distance  is  then  measured 
from  this  point  upward  and  backward  to  a  point  slightly  posterior  to 
the  trochanter.  The  ankle-joint  comes  at  a  point  opposite  the  inner 
malleolus. 


PRACTICAL   DETAILS    OF  APPARATUS.  637 

When  the  curve  involves  only  the  lower  tibia,  the  inner  upright 
need  not  be  carried  above  the  inner  condyle  of  the  femur,  where  it  ends 
in  a  circular  steel  pad  fastened  to  its  inside  to  press  on  the  inner  con- 
dyle of  the  femur,  which  is  finished  like  those  described  in  the  appara- 
tus for  bow-legs  and  knock-knee.  In  this  case  a  semicircular  band  is 
added  to  the  apparatus  just  below  the  upper  end,  fastening  around  the 
leg. 

20.    ANTERIOR    BOW-LEGS. 

In  addition  to  the  apparatus  described,  in  bow-legs  with  an  anterior 
curve  of  the  tibia  two  additional  parts  are  needed.  These  consist  of 
posterior  semicircular  strips  of  steel,  curved  to  the  outline  of  the  leg, 
one  fastened  to  the  upright  just  below  the  knee,  and  the  other  just 
above  the  heel.  These  are  connected  at  their  outer  ends  by  a  strip  of 
steel  running  from  the  outer  end  of  one  to  the  outer  end  of  the  other. 
These  furnish  points  for  the  attachment  of  buckles,  into  which  straps 
are  buckled  passing  from  an  anterior  leather  pressure  pad.  In  this 
way  backward  pull  is  exerted  upon  the  curved  portion  of  the  leg. 

21.    ANTERO-POSTERIOR    BOW-LEG    BRACE.' 

The  object  of  this  splint  is  to  prevent  as  far  as  possible  flexion  at 
the  knee,  while  pressure  is  exerted  upon  the  outward  bowing  of  the  leg. 
It  consists  of :  {a)  two  uprights ;  (b)  a  thigh  band ;  (c)  an  ankle  band ; 
id)  a  foot-piece. 

{a)  The  Uprights. — These  consist  of  pieces  of  sheet  steel.  No.  16 
gauge,  five-eighths  of  an  inch  wide.  The  anterior  runs  from  a  point 
one-quarter  of  an  inch  above  the  level  of  the  ankle  up  the  median  line 
of  the  leg  to  a  point  a  little  below  the  level  of  the  gluteal  fold.  It 
may  be  bent  slightly  outward  at  the  knee  if  necessary.  The  posterior 
upright  starts  three-eighths  of  an  inch  lower  than  the  anterior,  and 
runs  up  the  median  line  of  the  leg  behind  to  the  level  of  the  top  of  the 
anterior  upright. 

{b)  The  Thigh  Band. — This  is  a  fiat  strip  of  No.  16  gauge  sheet 
steel,  seven-eighths  of  an  inch  wide,  bent  to  fit  the  curve  of  the  thigh 
on  its  inner  side,  and  riveted  to  the  top  of  each  upright. 

{c)  The  ankle  band  is  a  similar  strip  of  steel  connecting  the  lower 
ends  of  the  uprights.  It  is  cut  somewhat  curved,  with  the  convexity 
downward,  that  its  middle  and  lowest  point  may  come  opposite  the  cen- 
tre of  the  internal  malleolus.  Both  bands  are  padded  on  their  inner 
surface  with  felt  and  covered  with  leather. 

id)  T\\Q.  foot-piece,  made  of  machine  steel  forged  to  fit  foot,  begins 
as  a  round  rivet  joint,  so  as  to  allow  motion  in  flexion  and  extension, 

'John  Dane:  Trans.  Am.  Orth.  Assn.,  vol.  .\i.,  p.  131. 


638 


ORTHOPEDIC  SURGERY. 


situated  in  the  centre  of  the  ankle  band ;  it  extends  downward  to  the 
level  of  the  sole  of  the  shoe,  where  it  is  bent  inward  at  a  right  angle 
beneath  the  sole  and  expanded  into  a  flat  plate,  which  is  riveted  to  the 
sole.  The  heel  of  the  shoe  is  then  replaced,  covering  the  posterior  por- 
tion of  this  plate. 

Two  flaps  of  leather  are  riveted  one  upon  each  of  the  uprights, 
beginning  at  the  bottom  and  reaching  to  just  below  the  knee,  or 
three-quarters  up  the  thigh,  according  to  the  location  of  the  bowing. 
These  are  of  such  a  width  that  they  overlap  each  other  slightly 
around  the  outer  side  of  the  leg,  and  are  finished  with  a  row  of  holes 
or  eyelets  for  lacing  them  together.  A  strap  and  buckle  are  riveted 
to  the  extremities  of  the  thigh  band,  to  pass  round  the  outer  side  of 
the  leg. 

22.    TEMPERED    STEEL    UPRIGHTS. 

This  form  of  apparatus  consists  of  {a)  a  horizontal  pelvic  band,  (b) 
two  uprights,  and  {c)  a  cross-bar. 

{a)  The  horizontal  pelvic  band  encircles  the  posterior  part  of  the 
pelvis  from  a  point  one  inch  posterior  to  the  anterior  superior  spine 

on  one  side  to  a  similar  point  on 
the  other  side.  It  is  curved  to 
fit  the  contour  of  the  pelvis  and 
should  lie  close  against  it.  It  is 
made  of  No.  15  gauge  sheet  steel, 
one  and  one-eighth  inches  wide. 
The  uprights  run  from  the  pos- 
terior pelvic  band  along  the  sides 
of  the  spine  to  a  point  about  on 
a  level  with  the  acromion  process. 
At  this  point  they  are  curved 
outward  on  the  flat  by  an  angular 
turn  at  an  angle  of  about  forty- 
five  degrees,  and  run  upward  and 
outward  to  a  point  just  behind 
the  anterior  border  of  the  trape- 
zius. In  their  upper  part  they 
are  curved  to  fit  the  contour  of 
the  shoulders  and  should  lie  flat 
against  the  skin. 

ib)  The  uprights  at  their 
lower  part  are  farther  from  each  other  than  they  are  at  the  top.  At 
the  bottom  their  outer  edges  should  be  separated  by  a  distance  some- 
what less  than  the  distance  between  the  two  posterior  superior  spines. 
At  the  top  they  should  lie  over  the  transverse  processes.     They  are 


Fig.  573. — Tempered  .Steel  Uprights. 


PRACTICAL  DETAILS   OF  APPARATUS.  639 

made  of  No.  16  gauge  sheet  steel,  five-eighths  of  an  inch  wide,  and 
should  follow  the  outline  of  the  back  in  general,  but  whatever  correc- 
tion is  desired  in  the  standing  position  is  to  be  made  by  bending  the 
uprights  to  fit  the  curve  of  the  back  in  a  corrected  position  rather 
than  the  cur\-e  of  the  back  in  the  faulty  position. 

ic)  The  cross-bar  consists  of  a  piece  of  steel,  which  in  length  should 
be  one  inch  less  on  each  side  than  the  breadth  of  the  body  at  the  level 
where  it  is  placed.  It  is  riveted  transversely  to  the  uprights  at  a  point 
just  below  the  posterior  fold  of  the  axilla.  The  projecting  ends  beyond 
the  bars  should  not  rest  on  the  scapuLne,  but  if  necessary  should  be  set 
backward  by  an  angular  curve  to  clear  the  scapulas.  These  are  made 
of  the  same  material  as  the  uprights. 

Buckles. — Holes  are  drilled  for  buckles  at  each  anterior  end  of  the 
pelvic  band,  at  the  top  of  the  uprights,  and  at  the  ends  of  the  cross-bar. 
Buckles  are  placed  on  the  ends  of  the  pelvic  band,  and  the  cross-bar 
and  axillary  straps  are  riveted  to  the  upper  ends  of  the  uprights,  one  on 
each  side.  The  brace  is  finished  by  being  covered  with  leather  sewed 
down  the  back  throughout,  or  by  being  nickel-plated  and  having  its  an- 
terior surface  only  covered  with  padded  leather  strips  slightly  wider 
than  the  metal  parts  of  the  brace.  These  are  attached  to  the  brace  by 
loops  running  around  the  uprights,  pelvic  band,  and  the  cross-bar. 
The  brace  is  attached  to  the  body  at  the  top  by  means  of  axillary 
straps  similar  to  those  described  in  speaking  of  the  antero-posterior 
support,  and  by  means  of  a  broad  belt  of  sheep-skin  or  surcingle  cloth, 
to  each  end  of  which  webbing  or  leather  straps  are  sewed,  which  con- 
nect the  anterior  ends  of  the  pelvic  band  by  passing  around  the  lower 
part  of  the  bottom.  In  cases  in  which  there  is  much  prominence  of 
the  abdomen,  it  is  desirable  to  add  an  abdominal  band,  from  four  to  six 
inches  wide,  running  from  one  upright  around  the  bottom  to  the  other 
upright. 

23.  BRACE  WITH  MOVABLE  SHOULDER-PIECES. 

This  brace  is  really  the  tempered  steel  brace  already  described,  with 
a  special  cross-bar  and  shoulder-pieces  at  the  top.  It  consists  of:  {a) 
a  waist  band  ;  ib)  two  uprights ;  (r)  a  cross-piece,  bearing  at  each  end  a 
movable  L-shaped  shoulder-piece. 

{a)  The  ZK.<aist  band  is  to  be  made  and  finished  as  described  for  the 
tempered  steel  brace. 

{b')  The  uprights  likewise,  except  that  they  should  end  straight  at 
the  level  of  the  first  dorsal  spine,  and  that  the)-  should  be  one  inch 
apart  throughout. 

(c)  The  cross-piece— ?L  plate  of  sheet  steel,  four  to  four  and  one-half 
inches  long,  one  inch  wide,  and  one-sixteenth  of  an  inch  thick — is  riv- 


640 


ORTHOPEDIC  SURGERY. 


eted  with  its  front  face  to  the  top  of  the  uprights  by  four  iron  rivets. 
One-quarter  of  an  inch  from  each  outer  edge  is  a  rivet  hole  for  attach- 
ment of  the  shoulder-piece,  which  is  riveted  loose,  so  as  to  allow  the 
shoulder-piece  to  move  freely  in  one  plane ;  the  L-piece  is  fastened  to 
the  front  face  of  this  cross-plate,  one-half  of  an  inch  from  the  rounded 
inner  edge  of  the  L-piece.  The  L-piece  is  made  of  the  same  material, 
one-sixteenth  of  an  inch  thick,  of  a  uniform  width  of  one-half  of  an 
inch.     The  attached  arm  should  extend  horizontally  to  a  point  on  the 


Fig.  574. 


-Back  Brace  with  Movable  Shoulder- 
pieces.     (A.  Thorndike.) 


Fig.  575. — Front  View  of  Straps  and  Apron  in 
Back  Brace  with  Movable  Shoulder-pieces. 


shoulder  vertically  above  the  posterior  axillary  fold  when  the  arm  is  at 
the  side,  from  which  point  the  other  arm  descends  at  right  angles 
three  inches.  A  pattern  of  stiff  paper  should  be  made.  A  webbing 
strap,  four  inches  long,  bearing  a  buckle  one  inch  from  the  free  end,  is 
■  riveted  to  the  angle,  and  another  eight  inches  long  to  the  tip  of  the  un- 
attached arm  of  the  L-piece.  The  webbing  should  be  about  five-eighths 
of  an  inch  wide  and  needs  no  padding ;  for,  as  the  shoulder-pieces  and 
straps  follow  the  movements  of  the  arm,  they  do  not  rub.  A  piece  of 
thick  leather  covers  the  front  of  the  upper  third  of  the  uprights  and  the 
cross-piece,  to  prevent  the  inward  movement  of  the  posterior  border  of 
the  shoulder-blades  pinching  the  skin  against  the  uprights.  The  finish 
should  correspond  to  the  rest  of  the  brace. 


PRACTICAL   DETAILS    OF  APPARATUS. 


641 


24.    TORTICOLLIS    BRACE. 

The  brace  for  the  retention  of  the  head  in  the  overcorrected  posi- 
tion after  operation  for  torticolHs  is  a  modification  of  the  brace  already 
described  as  the  anterior  head  support.  It  consists  of  {a)  a  chest-  and 
shoulder-piece  which  serves  as  a  base  for  the  rest  of  the  apparatus,  (/;) 
a  wire  chin-piece,  and  (<r)  an  occipital  piece  of  steel. 

{a)  The  chest-  and  sJioiildcr-picce  is  not  made  of  wire,  as  in  the  ante- 
rior support,  but  of  flat  cast  steel,  one-half  of  an  inch  wide.  No.  8  gauge. 
In  front  it  is  curved  in  the  shape  of  a 
U,  and  its  bottom  part  is  as  wide  as 
the  horizontal  distance  between  the 
middle  of  the  clavicles  running  at  the 
level  of  the  xiphoid  cartilage.  From 
this  level  it  is  curved  on  the  flat  to 
run  up  the  front  of  the  chest  vertically 
on  each  side.  It  is  bent  to  rest  on 
the  shoulders,  not  bearing  on  the 
clavicle,  and  each  side  of  the  upright 
is  then  continued  down  the  back  to 
about  the  level  of  the  tenth  rib,  being 
curved  to  fit  the  back.  It  is  padded 
with  felt  and  covered  with  leather 
stitched  on  the  side  away  from  the  skin. 
Its  lower  posterior  ends  are  to  be  pro- 
vided with  one  buckle,  into  which  is 
fastened  a  strap  going  around  the 
chest.  At  a  point  just  below  the  pos- 
terior fold  of  the  axillae  are  fastened 
two  other  buckles  on  the  upright,  from 
which  pass  straps  along  the  sides  of 
the  chest  below  the  axilla  into  buckles 
attached  to  the  vertical  part  of  the  U-piece  at  an  appropriate  level. 

(Jf)  The  chin-piece  is  identical  in  construction  with  that  described  in 
the  anterior  head  support,  except  that  the  hard-rubber  or  celluloid  pad 
for  the  chin  is  set  to  one  side  of  the  middle  line  of  the  ring,  and  the 
side  of  the  chin-piece  with  which  it  is  desired  to  make  pressure  upon 
the  chin  to  twist  the  head  is  carried  up  into  a  flange  following  the  con- 
tour of  the  jaw,  to  a  point  half-way  from  the  tip  of  the  chin  to  the  angle 
of  the  jaw.  This  chin-piece  ig  put  in  any  position  which  serves  to  hold 
the  head  with  the  required  amount  of  twist. 

((f)  The  occipital  piece  is  made  of  a  strip  of  machine  steel,  one- 
eighth  of  an  inch  thick  and  three-eighths   of  an  inch  wide,  running 
horizontally  behind  the  head  and  bent  around  the  wire  upright  on  one 
41 


Fig.  576. —Torticollis  Brace. 


642 


ORTHOPEDIC  SURGERY. 


side,  forming  a  hinge,  and  secured  to  the  opposite  upright  by  a  hook 
catch  made  by  bending  over  its  end.  From  one  side  of  this  upright 
there  runs  up  a  steel  stem  of  wire,  three-eighths  of  an  inch  in  diameter, 
flattened  at  its  lower  end  and  riveted  to  the  occipital  piece.  This 
should  rise  to  the  level  of  the  parietal  eminence  of  the  head.  Riveted 
to  this  at  its  top,  which  should  be  flattened,  is  a  pad  of  steel  or  phos- 
phor bronze,  oval  in  shape,  approximately  two  inches  in  height  by  three 

inches  in  breadth,  which  is  shaped  to  fit 
the  contour  of  the  head  and  tips  the 
head  to  the  desired  side.  This  pad  is 
padded  by  felt  and  covered  with  leather. 

25.    CALIPER   APPARATUS    FOR 
ANTERIOR  POLIOMYELITIS. 

A  modification  of  the  Thomas  cal- 
iper splint  is  the  simplest  apparatus  for 
cases  of  paralysis  of  the  leg,  in  which 
the  power  of  the  extensor  muscles  of 
the  thigh  is  not  sufficient  to  hold  the  leg 
straight  in  standing  or  walking.  It  is 
also  to  be  used  in  cases  of  spastic  par- 
alysis in  which  it  is  desired  to  hold  the 
knee  extended.  The  apparatus  consists 
of  {a)  two  uprights  and  {b)  a  posterior 
thigh  band. 

{a)  The  Upright. — The  inside  of  the 
upright  runs  from  the  bottom  of  the 
sole  of. the  shoe  to  a  point  at  least  one 
inch  below  the  perineum.  The  outer 
upright  runs  from  the  sole  of  the  boot 
to  a  point  at  least  one  and  one-half 
inches  below  the  top  of  the  great  tro- 
chanter. A  line  connecting  these  two 
points  should  be  at  least  one  inch  be- 
low the  fold  of  the .  buttock.  At  the 
lower  end  of  the  uprights,  where  they 
are  ort  a  level  with  the  bottom  of  the  sole  of  the  shoe,  each  upright  is 
turned  inward  at  a  right  angle  for  a  distance  of  at  least  one  inch,  to 
fasten,  into  a  hole  in  the  bottom  of  the  heel  of  the  shoe,  as  described 
in  the. Thomas  caliper  splint.  The  uprights  may  be  curved  to  follow 
the  inside  and  the  outside  of  the  leg,  but  are  stronger  if  they  are  left 
straight.  They  are  slightly  less  noticeable  if  they  are  curved  to  follow 
the  outline  of  the  leg. 

{b)  The  posterior  thigh  band  is  made  of  a  strip  of  sheet  steel,  one 


Fig.  577.— ^Caliper  Apparatus  for  Ante 
rior  Polioinyelitis. 


PRACTICAL  DETAILS   OF  APPARATUS.  643 

and  one-quarter  inches  wide  and  one-sixteenth  of  an  inch  thick,  encir- 
cling the  posterior  half  of  the  upper  part  of  the  thigh  and  shaped  to  fit 
it.  It  is  soldered  to  the  upper  parts  of  the  uprights  and  made  straight 
across  or  slanting  downward  from  without  inward.  It  should  be  padded 
with  felt  and  covered  with  leather.  The  knee  is  held  in  extension  by 
an  oblong  piece  of  leather,  four  inches  long  and  three  and  one-half 
inches  wide,  made  of  sole  leather  and  faced  with  sheep-skin.  In  its  cen- 
tre is  cut  a  hole,  the  size  of  the  patella,  in  order  to  avoid  pressure  on 
that  bone.  From  the  top  and  bottom  on  each  side,  stitched  to  the  an- 
terior surface  of  the  knee-cap,  a  strap  six  inches  long  and  one-half  of  an 
inch  wide  runs  sideways,  passing  around  the  upright  and  back  to  buckle 
at  the  knee-cap  at  the  origin  of  the  strap.  To  prevent  the  knee-cap 
from  slipping  down,  it  is  desirable  to  solder  on  the  outside  of  the  up- 
right, where  the  strap  passes  round  it,  a  small  wire  loop,  through  which 
pass  the  two  top  straps.  In  cases  in  which  very  much  pressure  comes 
upon  the  knee-cap,  it  may  be  modified  by  anterior  bands  of  leather  run- 
ning from  one  upright  to  the  other,  at  the  lower  third  of  the  thigh  and 
the  upper' third  of  the  calf.  These  bands  are  made  in  the  same  way 
and  of  the  same  material  as  the  knee-cap. 

26.    SUPPORTING   LEG   BRACE    FOR   ANTERIOR   POLIO- 
MYELITIS. 

In  infantile  paralysis  involving  the  leg  and  foot,  it  is  frequently  nec- 
essary that  a  supporting  brace  to  prevent  flexion  or  hyperextension  of 
the  knee  should  extend  up  from  the  foot-piece.  This  may  be  jointed  at 
the  knee  to  enable  the  patient  to  sit  down  with  greater  comfort.  This 
apparatus  consists,  in  addition  to  the  foot-piece,  of  {a)  two  uprights,  {b) 
two  or  three  posterior  calf  bands,  and  is  used  only  in  connection  with 
one  of  the  foot-pieces  described  in  speaking  of  the  various  deformities 
of  the  foot  caused  by  infantile  paralysis,  in  connection  with  one  of 
which  it  should  always  be  used.  Another  form  of  the  apparatus, 
shown  in  the  figure,  has  only  one  upright. 

{a)  The  outside  jipright  runs  from  the  point  opposite  the  outer  mal- 
leolus to  a  point  one  and  one-half  inches  or  more  below  the  trochanter. 
It  should  be  made  of  flat  machine  steel,  five-eighths  of  an  inch  wide, 
one-quarter  of  an  inch  thick,  and  should  be  curved  to  follow  the  outline 
of  the  leg,  a  space  being  left  so  that  the  upright  will  not  touch  the  outer 
malleolus  or  the  outer  surface  of  the  knee-joint.  For  the  rest  of  its 
course  it  should  be  closely  applied  to  the  leg.  The  inner  upright  is 
made  in  the  same  way,  running  from  the  internal  malleolus  to  a  point 
one  inch  or  more  below  the  perineum.  A  line  connecting  the  two  up- 
rights, passing  round  the  back  of  the  thigh,  should  be  oblique  and  lie 
at  least  one  inch  below  the  fold  of  the  buttock.     Both  uprights  should 


644 


ORTHOPEDIC  SURGERY. 


be  jointed  at  the  knee  by  antero-posterior  joints  moving  in  the  same 
plane,  and  the  outer  joint  should  be  furnished  with  a  drop  or  spring 
catch,  to  be  loosened  when  the  patient  sits  down.  The  upper  thigh 
band  should  be  three  inches  wide  at  its  outer  end  and  one  and  three- 
quarters  inches  wide  at  its  inner  end,  and  should  form  the  posterior 
half  of  a  circle,  being  shaped  to  fit  the  back  of  the  thigh.  It  is  riveted 
to  the  inside  of  the  top  of  the  uprights,  and  is  made  of  sheet  steel,  No. 
15  gauge.  ,--'^' 

{b)  There  should  ho.  posterior  bands  at  the  lower  third  of  the  thigh 
and  the  upper  third  of  the  calf,  one  inch  wide  and  made  of  the  same 


Fig.  S78.— Supporting   Leg  Brace  for    Ante- 
rior Poliomyelitis,  with  One  Upright. 


Fig.  579. 


-Mechanism  for  Locking  Knee-joint. 
(H.L.Taylor.) 


steel,  curved  to  fit  the  posterior  surface  of  the  thigh  and  calf,  riveted 
to  the  uprights.  Below  the  ankle-joint  the  apparatus  is  the  same  as 
that  described  in  speaking  of  the  various  forms  of  talipes.  The  meas- 
urements of  the  apparatus  have  been  indicated  in  describing  the  differ- 
ent parts  of  it.  The  apparatus  may  or  may  not  require  a  knee-cap, 
and  the  thigh  and  leg  are  supported  by  cuffs  of  leather  running  from 
the  top  of  the  splint  to  just  above  the  knee  and  from  the  tubercle  of 
the  tibia  to  a  point  two  inches  above  the  malleolus.  These  straps  are 
split  in  the  middle  line  in  front,  and  fit  the  calf  and  thigh  closely  be- 


PRACTICAL  DETAILS   OF  APPARATUS. 


645 


hind,  and  are  laced  by  means  of  hooks  or  eyelets  placed  at  one-half- 
inch  intervals  near  the  front  border  of  the  cuff. 

In  case  the  foot-piece  has  only  one  upright,  it  is  connected  with  the 


rT^^^^,vS^ 


Fig.  5S0.— Self-locking  Spring  Catch. 


Fig.  581. — Drop  Catch. 


leg  part  of  the  apparatus  as  follows :  The  upright  running  from  the 
foot-piece,  whether  on  the  outside  or  inside,  is  made  heavier  than  the 


Fig.  582.— Supporting  Apparatus  in  Paralysis  of  Anterior  Thigh  Muscles, 


646 


ORTHOPEDIC  SURGERY. 


other.  At  the  lower  third  of  the  calf,  the  upright  which  is  not  con- 
nected with  the  foot-piece  is  turned  backward  at  a  right  angle,  being 
curved  on  the  flat,  and  runs  around  the  back  of  the  calf,  being  curved 
with  its  convexity  backward,  and  is  riveted  at  its  free  end  to  the  outer 
side  of  the  long  upright  which  connects  with  the  foot-piece.  It  should 
run  transversely  across  and  should  be  closely  applied  to  the  back  of  the 
calf.  Above  this  point  the  apparatus  is  the  same  as  that  described 
above,  except  that  the  upright  connecting  with  the  foot-piece  must  nec- 
essarily be  somewhat  heavier  than  the  other. 

The  apparatus  thus  consists  of  a  foot-piece ;  an  upright  connecting 
with  it  either  on  the  outside  or  the  inside,  running  the  whole  length  of 
the  leg ;  and  another  upright  running  from  the  lower  third  of  the  calf 
the  whole  length  of  the  leg,  or  one  upright  may  be  used  passing  be- 
hind the  calf  as  described.  Either  form  of  apparatus  is  finished  by 
being  nickel-plated,  blued,  or  japanned. 

The  form  of  foot-piece  required  to  complete  the  leg  apparatus  is 
determined  by  the  kind  of  deformity  existing  in  the  foot. 

27.    EQUINO-VARUS    SPLINT. 
This  apparatus  consists  of  {a)  a  sole  plate,  ib)  an  upright,  and  {c)  a 
calf  band. 

(rt)  The  sole  plate  consists  of  a  bottom  part  and  side  flanges.  The 
sole  plate  is  made  of  sheet  steel,  No.  16  gauge.  The  bottom  part  is 
shaped  to  fit  the  weight-bearing  portion  of  the  normal  sole.  The  plate 
is  cut  so  that  flanges  can  be  turned  up  to  furnish  press- 
ure on  the  inner  side  of  the  end  of  the  os  calcis  and 
the  head  of  the  first  metatarsal  and  its  adjacent  pha- 
lanx. The  intervening  space  on  the  inner  side  of  the 
plate  is  cut  out  to  lighten  the  brace. 

Length. — The  sole  plate  should  extend  from  the 
posterior  border  of  the  heel  to  the  heads  of  the  meta- 
tarsals.    The  forward  side  flange  should  extend  from 
the  proximal  end  of  the  head  of  the  first  metatarsal  to 
the  joint  between  the  phalanges  of  the  great  toe.     The 
posterior  side  flange  presses  on  the  inner  side  of  the 
OS  calcis,  on  the  portion  posterior  to  a  line 
from  the  internal  malleolus  extending  down- 
ward.    The  plate  is  in  front  as  wide  as  the 
breadth  of  the  ball  of  the  foot,  and  behind 
as  the  width  of  the  os  calcis.     The  shape 
of  the  plate  can  be  indicated  by  cutting  it 
out  of  cardboard  and  fitting  it  to  the  foot. 

{b)  The  itprigJit  extends  up  the  side  of  the  leg  and  consists  of  two 
parts,  a  lower  and  an  upper,  five-eighths  of  an  inch  wide  and  one-quar- 


FIG.   583. 


■Splint    for  E^quino- 
varus. 


PRACTICAL  DETAILS   OF  APPARATUS. 


647 


ter  of  an  inch  thick.     The  lower  part  is  of  steel  plate,  No.  8  gauge,, 
forged  at  the  bottom  to  fit  the  posterior  part  of  the  sole  plate,  to  which 


Fig.  584. — Inner  and  Outer  Views. 


it  is  fastened  by  three  steel  rivets.  It  is  bent  at  right  angles  on  the 
inner  edge  of  the  sole  plate,  and  extends  on  the  line  of  the  internal 
malleolus  as  high  as  one-half  of  an  inch  above  the  malleolus. 


Fig.  585.— Club-foot  Shoe,  from  Front  and  Back.     Arrows  show  direction  of  force  exerted  by 

straps. 

The  upper  part  is  a  flat  steel  bar,  one-half  to  three-quarters  of  an 
inch  wide  and  No.  10  gauge,  and  extends  from  just  below  the  malleo- 
lus to  the  level  of  the  insertion  of  the  inner  hamstring. 


6^8 


ORTHOPEDIC  SURGERY. 


In  order  to  prevent  the  dropping  of  the  foot  into  the  position  of 
equinus,  the  joint  opposite  the  inner  malleolus  is  made  as  follows :  The 
two  parts  of  the  upright  which  join  at  this  place  are  flattened  into  cir- 
cular discs,  one  inch  in  diameter,  and  the  centre  is  pierced  with  a  hole 
for  a  steel  rivet,  making  an  antero-posterior  joint.  In  order  to  pre- 
vent the  dropping  of  the  foot,  the  front  lower  edge  of  the  flattened  disc 
on  the  lower  end  of  the  upright  is  ground  away  for  a  distance  of  one- 
quarter  of  an  inch,  beginning  at  the  middle  of  its  lower  part.     This 


a 


c 


F1G.5S6. — Details  of  Construction. 


leaves  a  sharp  projecting  lip  at  the  middle  of  its  lower  surface,  which 
strikes  against  a  pin  inserted  into  the  other  disc  forming  the  joint,  and 
checks  plantar  flexion  of  the  foot,  although  allowing  dorsal  flexion. 

The  upright  is  bent  in  such  a  way  as  not  to  strike  the  internal  mal- 
leolus when  the  foot  is  placed  in  a  position  of  valgus. 

{c)  The  calf  band  consists  of  a  leather  strap  going  around  the  leg, 
which  starts  from  and  is  buckled  to  a  small  steel  plate  at  the  top  of  the 
upright. 

Leather  and  Straps. — The  sole  plate  is  covered  by  thin  calfskin,  felt 
being  placed  between  the  leather  and  the  side  flanges  of  the  foot-piece. 
Strong  webbing  straps  are  furnished  to  secure  the  foot  in  the  sole  plate 
and  to  press  the  head  of  the  os  calcis,  the  astragalus,  and  the  external 
malleolus  to  the  inner  side.  These  straps  are  fastened  on  the  outer 
side  to  a  triangular  piece  of  leather  riveted  to  the  sole  plate,  and  extend 


PRACTICAL  DETAILS    OF  APPARATUS.  649 

on  the  outer  side  so  as  to  furnish  pressure  on  the  outer  side  of  the  os 
calcis.  The  straps  pass  around  the  ankle  and  are  secured  to  catches  or 
buckles  placed  on  the  lower  and  broader  portion  of  the  upright. 

The  front  strap  passes  through  a  steel  guard  attached  to  the  upright 
at  the  level  of  the  ankle,  which  protects  the  strap  from  chafing  the  up- 
right. 

A  strap  to  keep  the  heel  down  is  sometimes  needed.  It  is  riveted 
to  the  sole  plate,  passes  on  both  sides  of  the  ankle,  and  is  secured  by  a 
buckle  in  front  of  the  ankle.  Felt  is  needed  to  prevent  the  skin  from 
being  chafed.  A  strap  runs  across  the  front  of  the  foot  to  keep  the 
foot  close  to  the  plate. 

28.  APPARATUS  FOR  TALIPES  EQUINUS. 

For  uncomplicated  talipes  equinus  two  types  of  apparatus  are  in  use. 
This  apparatus  consists  of  («)  one  or  two  uprights,  {b)  a  foot-piece, 
and  {c)  a  posterior  calf  band. 

{a)  The  uprights  are  one  or  two  in  number.  If  two  are  used,  one  is 
outside  and  one  inside  the  leg,  and  these  run  from  the  bottom  of  the  ankle- 
joint  outside  of  the  boot  to  a  point  one  inch  below  the  tubercle  of  the 
tibia,  where  they  are  joined  by  a  posterior  calf  band.  They  are  made 
of  cast  steel.  No.  10  gauge,  and  should  be  shaped  to  follow  the  outline 
of  the  leg,  clearing  the  malleolus.  At  the  bottom  the  upright  proper 
ends  at  the  ankle-joint,  the  part  below  the  ankle-joint  being  considered 
the  foot-piece.  The  lower  end  of  the  upright  is  flattened  into  a  circu- 
lar disc,  five-eighths  of  an  inch  in  diameter,  and  its  centre  is  drilled  for 
a  hole  for  the  connecting  spindle  of  the  joint.  Both  uprights  are  finished 
in  the  same  way,  the  level  of  the  joint  being  just  below  the  prominent 
part  of  the  internal  malleolus.  If  one  upright  is  used,  it  should  be 
made  of  sheet  steel.  No.  10  gauge,  and  ends  in  a  posterior  calf  band 
fastened  around  the  leg  by  a  strap  and  buckle. 

{b)  T\\Q  foot-pitxe  consists  of  a  sole  plate  and  two  pieces  running  up 
to  join  the  uprights.  The  sole  plate  consists  of  a  piece  of  sheet  steel, 
No.  17  gauge,  with  a  straight  posterior  edge,  which  runs  far  enough 
back  to  pass  between  the  heel  of  the  boot  and  the  sole  of  the  shoe, 
being  covered  by  the  heel  of  the  boot.  Its  anterior  end  then  runs 
along  the  under  side  of  the  shank  of  the  boot  for  a  distance  of  one-half 
of  an  inch,  being  covered  on  its  anterior  part  by  an  extra  piece  of  sole 
leather,  tapped  on  to  the  bottom  of  the  sole  of  the  boot  covering  in  the 
front  of  the  foot-piece.  The  steel  tongue  which  runs  forward  should  be 
narrower  than  the  shank  of  the  boot  and  run  well  forward  to  the  meta- 
tarso-phalangeal  joint.  It  is  riveted  to  the  sole  of  the  shoe  through 
holes  drilled  in  it  in  three  or  four  places.  The  side  arms  of  the  foot- 
piece  should  be  at  least  one-quarter  of  an  inch  wider  than  the  foot 


650 


ORTHOPEDIC  SURGERY. 


where  they  pass  up  at  the  edge  of  the  sole.  They  should  be  turned 
up  at  a  right  angle  to  join  the  lower  ends  of  the  upright,  and  should 
be  flattened  and  drilled  as  described  to  form  a  joint  with  the  lower 
ends  of  the  upright. 

Joint. — In  order  to  prevent  the  plantar  flexion  of  the  foot,  which  is 
the  deformity  to  be  corrected  in  talipes  equinus,  the  joint  must  be  con- 
structed in   the   same  way  as  in  the  splint 
for  equino-varus  to  prevent  dropping  of  the 
foot. 

{c)  The  posterior  calf  band  at  the  top  of 
the  upright  is  made  of  No.  17  gauge  sheet 
steel,  riveted  to  the  inner  surface  of  the  up- 
right or  uprights  at  the  top,  and  curved  to  fit 
the  calf  of  the  leg.  This  is  padded  with  felt, 
covered  with  leather,  and  provided  with  a 
strap  and  buckle  to  pass  round  the  anterior 
part  of  the  leg. 

The  apparatus  may  be  finished  by  being 
nickel-plated,  blued,  or  japanned. 

x^nother  type  of  apparatus  may  be  used 
for  uncomplicated  talipes  equinus,  which  is 
less  unsightly,  as  it  goes  inside  the  boot.  It 
consists  of  {a)  a  foot-piece,  {b)  two  up- 
rights, {/)  a  posterior  calf  band,  and  in  con- 
struction it  follows  the  lines  indicated  in 
speaking  of  the  fixation  splint  for  ankle- 
joint  disease,  except  that  it  is  jointed  oppo- 
site the  malleolus  and  that  no  lacing  over  the  foot  is  required.  It  is 
not  attached  to  the  boot. 

(c?)  The  foot  plate  is  covered  with  a  smooth  piece  of  thick  leather, 
riveted  on,  and  is  worn  inside  the  boot.  The  joint  at  the  ankle  is  of 
the  same  kind  as  that  described  in  the  apparatus  just  mentioned  for 
talipes  equinus  with  a  right-angle  stop-catch.  The  apparatus  in  other 
respects  presents  no  difference. 


Fig.  587.— Apparatus  for  Tali- 
pes EquinuSjWith  Stop  Catch. 
On  the  right  of  the  picture  is 
a  detail  drawing  of  the  stop 
for  talipes  calcaneus,  on  the 
left  a  catch  allowing  slight 
motion. 


Apparatus    for   Talipes    Equinus  Complicated  with  Varus  or 

Valgus. 


The  apparatus  for  equino-varus  has  already  been  described.  When 
talipes  equinus  exists  with  any  degree  of  valgus,  the  shoe  described  in 
speaking  of  talipes  valgus  is  the  most  useful,  and  the  only  modification 
necessary  in  it  is  the  addition  of  a  right-angle  stop-catch  to  prevent 
plantar  flexion  of  the  foot.  This  is  identical  in  construction  with  the 
joint  described  in  speaking  of  the  apparatus  for  equinus. 


PRACTICAL  DETAILS   OF  APPARATUS.  65  I 

29.    APPARATUS    FOR   TALIPES    CALCANEUS. 

For  uncomplicated  cases  of  talipes  calcaneus  the  forms  of  appa- 
ratus described  for  talipes  equinus  are  to  be  used,  with  a  simple  mod- 
ification.' This  modification  consists  in  reversing  the  stop-joint  at 
the  ankle,  so  that  it  prevents  dorsal  flexion  but  allows  plantar  flexion 
to  the  foot.  This  is  done  by  cutting  away  the  posterior  half  of  the 
lower  surface  of  the  disc  forming  the  lower  end  of  the  upright,  and 
putting  a  pin  in  the  part  of  the  foot-piece  at  such  a  place  that  it  will 
strike  against  the  projecting  lip  left  at  the  anterior  half  of  the  lower 
border  of  the  foot-piece.  It  is  only  necessary  to  do  this  over  the  outer 
malleolus,  and  the  inner  joint  may  be  left  free.  The  construction  in 
other  respects  is  the  same  as  that  described  in  speaking  of  the  joint  for 
talipes  equinus.  If  talipes  calcaneus  exists  with  either  varus  or  valgus, 
the  varus  or  valgus  shoe  with  a  steel  sole  plate  should  be  provided  with 
an  appropriate  stop-joint. 

30.  APPARATUS  FOR  TALIPES  VARUS. 

For  cases  of  a  severe  grade  the  splint  described  for  the  treatment 
of  equino-varus  is  to  be  used,  without  the  right-angle  stop-catch  at  the 
ankle-joint. 

For  cases  of  lighter  grade  the  reverse  of  the  apparatus  described  for 
talipes  valgus  would  be  of  use.  In  this  apparatus  the  upright  and  foot- 
piece  should  run  up  the  inner  side  of  the  leg.  The  joint  is  opposite  the 
inner  malleolus,  and  the  T-strap  is  fastened  to  the  outer  border  of  the 
shank  of  the  boot  and  passes  around  the  external  malleolus.  This  ap- 
paratus is,  of  course,  much  less  efficient  than  the  one  just  described. 

31.   APPARATUS    FOR    TALIPES   VALGUS. 

The  deformity  in  talipes  valgus  is  most  easily  controlled  by  an  ap- 
paratus following  the  same  general  lines  in  its  construction  as  that  de- 
scribed for  equino-varus,  except  that,  of  course,  the  upright  runs  on  the 
outside  of  the  leg  and  the  pull  of  the  apparatus  is  reversed.  This 
apparatus  consists  of  {a)  an  upright,  (Jf)  a  sole  plate,  and  {c)  a  calf 
band. 

{a)  The  nprigJit  is  made  of  steel  similar  to  that  described  in  speak- 
ing of  the  shoe  of  equino-varus,  and  runs  from  a  point  one  inch  below 
the  tubercle  of  the  tibia,  where  it  terminates  in  a  band  forming  about 
one-third  of  a  circle  and  curved  to  fit  the  outer  contour  of  the  leg, 
avoiding  the  external  malleolus. 

((^i)  The  sole  plate  consists  of  a  flat  plate  of  No.  16  gauge  sheet 

'  See  Fig.  587.       ' 


652 


ORTHOPEDIC  SURGERY. 


steel,  turned  up  at  a  right  angle  along  its  outer  border  for  a  distance 
of  three-quarters  of  an  inch  to  follow  the  outer  border  of  the  foot. 
This  turned-up  edge  should  reach  from  behind  the  head  of,  the  fifth 
metatarsal  to  a  point  one-half  of  an  inch  in  front  of  the  posterior  part 
of  the  OS  calcis.  It  is  often  necessary  to  bend  it  out  or  cut  it  away 
over  the  base  of  the  fifth  metatarsal.  The  length  of  the  bottom 
of  the  plate  is  from  just  behind  the  cleft  between  the  toes  and  the  ball 


Fig.  588. — Apparatus  for  Talipes  Valgus. 

of  the  foot  to  a  point  one-half  of  an  inch  in  front  of  the  posterior  end 
of  the  OS  calcis.  Its  width  is  one-quarter  to  one-half  of  an  inch  less 
than  the  breadth  of  the  sole  of  the  foot.  It  is  generally  desirable  to 
arch  the  inner  surface  of  the  plate  somewhat  to  follow  the  curve  of  the 
arch  of  the  foot.  This  adds  to  the  efficiency  of  the  apparatus  by  help- 
ing to  antagonize  the  valgus  by  preventing  dropping  of  the  arch  and 
rolling  of  the  foot  on  to  its  inner  side. 

This  plate  is  connected  with  the  upright  by  means  of  a  right-angled 
piece  of  machine  steel,  No.  10  gauge,  three-quarters  of  an  inch  wide, 
which  runs  across  its  under  surface  and  is  riveted  to  the  sole  plate.  On 
the  outer  border  of  the  sole  plate  it  turns  up  at  a  right  angle  and  runs 
to  a  point  opposite  the  external  malleolus,  where  its  upper  end  is  flat- 
tened into  a  disc,  five-eighths  of  an  inch  in  diameter,  the  centre  of 
which  is  drilled  by  a  hole,  three-eighths  of  an  inch  in  diameter,  for  the 
insertion  of  a  spindle  which  connects  it  with  the  lower  end  of  the  up- 


« 


PRACTICAL  DETAILS   OF  APPARATUS.  653 

right.  In  the  case  of  a  pure  valgus  deformity  there  is  no  need  of  a 
stop-catch  at  the  joint.  If  the  valgus  is  associated  with  an  equinus  de- 
formity a  stop-catch  is  required,  of  the  kind  described  in  speaking  of 
the  apparatus  for  equinus.  If  it  is  associated  with  a  calcaneus  deform- 
ity the  reverse  stop  should  be  used,  which  is  described  in  speaking  of 
calcaneus. 

{c)  The  band  is  provided  with  a  strap  and  a  buckle  to  encircle  the 
leg,  and  is  padded  with  felt  and  covered  with  leather.  It  is  riveted  to 
the  inner  surface  of  the  top  of  the  upright. 

The  foot  is  fastened  to  the  sole  plate  by  means  of  two  or  three  web- 
bing straps,  which  are  riveted  to  the  inner  border  of  the  sole  plate,  pass 
over  the  dorsum  of  the  foot  and  the  turned-up  outer  edge  of  the  plate, 
to  fasten  into  clasps  described  in  the  shoe  for  equino-varus.  These  are 
fastened  on  to  the  outer  surface  of  the  turned-up  edge  of  the  foot  plate. 
One  of  these  straps  will  be  required  at  the  front  of  the  foot  and  one 
toward  the  posterior  part  of  the  foot  plate. 

The  essential  part  of  the  apparatus  is  a  T-strap,  which  passes  around 
the  inner  malleolus,  holding  it  outward.  This  strap,  which  should  be 
made  of  sole  leather,  is  fastened  at  its  base  to  the  upper  surface  of  the 
inner  border  of  the  foot  plate  directly  below  the  internal  malleolus.  It 
passes  upward  and  broadens  one  inch  below  the  malleolus  to  form  two 
straps,  which  run  at  right  angles  to  the  vertical  axis  of  the  leg.  The 
height  of  this  strap  should  be  the  distance  from  the  foot  plate  to  a  point 
one  inch  or  less  above  the  lower  border  of  the  internal  malleolus.  The 
horizontal  parts  of  the  T-strap  then  pass  outward  at  the  level  of  the 
malleolus  around  the  upright  and  below  the  malleolus.  One  strap  is 
furnished  with  a  leather  buckle,  five-eighths  of  an  inch  wide,  into  which 
the  other  end  of  the  strap  fastens.  It  is  desirable  that  this  buckle,  when 
fastened  in  place,  should  lie  against  the  outer  side  of  the  upright,  so 
that  it  does  not  lie  against  the  soft  parts. 

The  measurements  of  the  splint  are  self-evident.  A  cardboard  pat- 
tern of  the  sole  plate  should  be  furnished  and  the  length  given  from  the 
bottom  of  the  sole  plate  to  a  point  one  inch  below  the  tubercle  of  the 
tibia.  The  height  of  the  external  malleolus  from  the  sole  plate  is  given. 
The  posterior  band  is  one-third  of  the  circumference  of  the  calf  at  that 
level. 

A  simpler  and  lighter  apparatus  may  be  used  for  uncomplicated 
cases  of  talipes  valgus.  It  consists  of  (c?)  an  upright,  (/;)  a  foot-piece, 
and  {c)  a  calf  band. 

{a)  The  upright  extends  on  the  outside  of  the  leg  from  the  external 
malleolus  to  a  point  one  inch  below  the  tubercle  of  the  tibia.  It  is 
made  of  machine  steel  and  is  five-eighths  of  an  inch  wide.  It  is  fastened 
to  the  top  of  the  foot-piece  at  the  ankle-joint  by  means  of  a  free  joint 
similar  to  that  described  in  speaking  of  the  apparatus  for  knock-knee. 


654 


ORTHOPEDIC  SURGERY. 


{b)  The  foot-piece  is  similar  to  that  described  in  the  apparatus  for 
knock-knee,  and  is  fastened  to  the  bottom  of  the  shoe  and  runs  up  on 
the  outside  of  the  foot  to  join  the  upright  at  the  outer  malleolus. 

(c)  The  calf  band  is  like  that  described  in  the  other -appsiratus  for 
valgus.  The  apparatus  is  entirely  outside  of  the  shoe  and  is  put  on 
and  off  with  the  shoe.  The  T-strap  described  in  speaking  of  the  other 
apparatus  for  valgus  is  fastened  to  the  bottom  of  the  inside  of  the  shank 
of  the  boot  at  a  point  directly  below  the  internal  malleolus.  It  runs  up 
and  buckles  around  the  upright  of  the  splint  in  a  manner  similar  to  that 
described  in  speaking  of  the  other  apparatus  for  valgus,  except  that,  of. 
course,  it  is  outside  of  the  boot.  If  any  element  of  equinus  or  calcaneus 
exists,  an  appropriate  stop-joint  is  put  in  at  the  ankle,  as  has  been  de- 
scribed in  speaking  of  these  affections. 

32.    FLAT-FOOT    PLATES. 

The  details  of  the  manufacture  of  flat-foot  plates  have  been  so  fully 
described  in  the  chapter  on  fiat-foot  that  they  will  not  be  discussed  here 
(Chapter  XX.). 


Fig.  580.  -Flat-foot  Plates. 


Fig.  590. —  Flat- foot  Plate 
Raised  in  Front  to  Support 
Anterior  Arch. 


Fig.  591.— Flat-foot  Plate.    Right  foot. 


33.   TOE-POST. 

In  cases  of  hallux  valgus  it  is  frequently  desirable  to  introduce  a 
vertical  partition  in  the  line  of  the  length  of  the  foot  between  the  first 
and  second  toes,  in  order  to  hold  the  great  toe  in  a  correct  position. 
This  toe-post,  as  it  is  called,  may  be  held  in  place  in  one  of  two  ways. 


PRACTICAL  DETAILS   OF  APPARATUS.  655 

It  may  be  passed  up  through  an  inner  sole  fitting  accurately  in  the 
boot  in  which  case  it  may  be  moved  from  one  pair  of  boots  to  another ; 
or  it'  may  be  passed  up  through  the  sole  of  the  boot  from  the  under 
surface,  in  which  case  it  could  not,  of  course,  be  changed  from  boot  to 
boot.     The  description  in  this  connection  applies  to  the  case  of  an  adult. 
The  toe-post  at  its  posterior  border  is  situated  one-quarter  of  an  mch 
from  the  cleft  between  the  first  and  second  toes.     At  its  anterior  border 
it  should  not  reach  within  one-quarter  of  an  inch  of  the  front  end  of  the 
great  toe.     In  height  it  should  not  reach  above  the  top  surface  of  the 
great  toe  with  the  foot  resting  on  the  ground.     It  is  made  of  sheet  steel 
of  the  required  width  and  one-sixteenth  of  an  inch  in  thickness.     It  is 
cut  in  a  strip  three  and  one-half  inches  long  and  of  the  width  indicated. 
This  strip  is  then  folded  in  its  middle,  as  one  would  double  a  piece  of 
paper  by  creasing.     The  thickness  of  the  toe  from  the  top  to  the  bot- 
tom is  then  measured,  and  the  thickness  of  the  sole  is  added  to  this  and 
marked  on  the  folded  piece  of  steel.     At  this  point  a  sharp  right-angu- 
lar bend  is  made  on  each  side,  the  bent  ends  of    ^__yn  z::^ 
the  steel  forming  a  continuous  straight  line,  with    (Zlj\y   f...M 
which  the  double  upright  forms  a  right  angle.                    / 
The  ends  of  the  steel  are  then  cut   off  to  the                  / 
desired  length.     A  tracing  of  the  foot  is  then  made        [ 
on  a  piece  of  paper  and  the  desired  position  of  the  toe-        fV  71 
post  is  indicated  on  the  tracing.     A  vertical   slit  is         U  V 
then  made  in  the  boot  at  this  point,  and  the  vertical          \  I 
part  of  the  toe-post  is  passed  up  through  it  to  protrude            \  \ 
into  the  boot.     The  toe-post  is   more  comfortable  if             \  \ 
covered  with  a  thin  piece  of  leather  before  being  intro-              \  ) 
■   duced  into  the  shoe.     The  ends  of  the  steel  which  are               V^^ 
against  the  bottom  of  the  sole  are  then  fastened  in   ''l^^^^ZllZ 
place,  and  an  extra  tap  is  put  on  the  bottom  of  the  sole 
to  cover  in  the  piece  of  steel  which  has  been  fastened  to  the   bot- 
tom     Inside  of  the  boot  a  stall  is  thus  provided  for  the  great  toe.     It 
is  of  course,  necessary  in  the  use  of  the  toe-post  that  a  stockmg  shoiild 
be  worn  with  a  partition  between  the  first  and  the  second  toe.     The 
measurement  as  here  given  applies  to  the  use  of  the  toe-post  when 
permanently  fastened  to  the  shoe.     When  it  is  to  be  used  m  aninner 
sole    the    height   of  the   vertical  part    is   the    measurement    of    the 
thickness  of  the  toe.     It  is  then  passed  through  a  slit  in  an  inner  sole 
and  the  bottom  pieces  of  the  toe-post  are  fastened  to  the  sole  by  stitch- 
ing.    An  inner  sole  should  be  made  of  sole  leather  with  the  polished 
side  up,  cut  accurately  to  fit  the  sole  of  the  boot. 


INDEX. 


Abscess,  cold,  of  joints,  8 

in    tuberculous  disease  of  hip,  86, 

"5 
treatment,  130 
in  tuberculous  disease  of  knee,  153 
in  tuberculous  disease  of  spine,  19, 

49 
treatment.  79 

psoas,  39,  80 

retropharyngeal,  41,  80 
Acetabular  hip  disease,  84 
Achillobursitis,  599 
Achillodynia,  599 
Achondroplasia,  282 
Actinomycosis,  264 

of  spine,  264 
Amputation  for  hip-joint  disease,  144 

for  knee-joint  disease,  169 
Angular   curvature   of  spine,    16;   and 

Tuberculous  disease  of  spine 
Ankle,  congenital  dislocation  of,  515 

excision  of,  175 

functional  affections  of,  472 

splint  for,  632 

sprains  of,  227 

synovitis  of,  240 

tenosynovitis  of,  241 

tuberculous  disease  of,  171 
Ankylosis,  266 

and  immobilization,  127 

formation  of  new  joints  in,  269 

treatment,  268 
Anterior  poliomyelitis,  406 

apparatus  for,  431,  642,  643 

arthrodesis  in,  443 

caliper  apparatus  for,  642 

deformities  in,  413 
treatment,  435 

diagnosis,  421 

differential  diagnosis,  424 

dislocations  from,  419 

distribution  of  paralysis,  412 
42 


Anterior   poliomyelitis,  electrical    reactions 
96,  in,  421 

epidemic,  407 

etiology,  406 

excision  for,  444 
39,  hip  deformity  in,  436 

knock -knee  in,  416 

nerve  transplantation  in,  443 
twisting  in,  443 

osteotomy  for,  444 

paralysis   of    leg   and   thigh    muscles, 

431.  432 

apparatus  for,  642,  643 
pathology,  408 
prognosis,  426 

supporting  leg-brace  for,  643 
symptoms,  410 

talipes  calcaneo-valgus  in,  417 
see  calcaneus  in,  418 

equino-varus  in,  417 

equinus  in,  417 
tendon  transplantation  in,  439 
treatment,  427 

mechanical,  430 

operative,  438 
Apophysalgie  Pottique,  31 
Apparatus,  ankle  sphnt,  632 
anterior  bow-leg  irons,  637 

head  support,  613 
antero-posterior  bow -leg  brace,  637 

support  for  Pott's  disease,  607 
back  brace,  quadrilateral,  613 

quadrilateral,  wdth  head  support, 
617 
bandages,  celluloid,  605 

plaster-of-Paris,  601 
bed-frame,  gas-pipe,  618 
bow-leg  irons,  635 

brace  with  movable  shoulder-pieces,  639 
caliper,  for  anterior  poliomyelitis,  642 
celluloid  bandages,  605 
convalescent  hip  splint,  623 

657 


658 


INDEX. 


Apparatus,  double  upright  hip  splint,  625 
equino-varus  splint,  646 
fixation  ankle  splint,  632 
flat-foot  plates,  580,  654 
for  anterior  poliomyelitis,  642,  643 
for  bow-legs,  635,  637 
for  eqmno-varus,  646 
for  hallux  valgus,  654 
for  Pott's  disease,  607 
for  talipes  calcaneus,  651 
for  talipes  equino-varus,  646 
for  talipes  equinus,  649 
for  talipes  equinus  complicated  with 

varus  or  valgus,  650 
for  talipes  valgus,  651 
for  talipes  varus,  651 
gas-pipe  bed-frame,  618 
head  support,  anterior,  613 

oval  ring,  612 
hip  splints,  619,  623,  625 
jointed  knee  splint,  630 
knee  splints,  627,  629,  630 
knock -knee  brace,  633 
leather  splints  and  jackets,  606 
oval  ring  head  support,  612 
plaster-of-Paris  bandages,  601 
practical  details  of,  601 
quadrilateral  back  brace,  615 

with  head  support,  617 
supporting  leg  brace  for  anterior  poli- 
omyelitis, 643 
tempered  steel  uprights,  638 
Thomas  caliper  spUnt,  629 

collar,  615 

hip  sphnt,  625 

knee  splint,  627 
toe-post,  654 
torticollis  brace,  641 
traction  hip  splint,  619 
Aran-Duchenne  type  of  muscular  atrophy, 

463 
Arthritis,  ankylosing,  206 

chronic  rheumatic,  196  ;  and  see  Ar- 
thritis deformans 
Arthritis  deformans,  196 
atrophic,  205 
chronic,  109 

rheumatoid,  205 
comphcations,  201 
diagnosis,  207 
etiology,  201 
fibrinous,  206 


Arthritis  deformans,  in  children,  213 

local  treatment,  209 

localization,  202 

mechanical   treatment  of  deformities, 
212 

monarticular,  205 

of  hip,  217 

of  knee.  219 

of  shoulder,  222 

of  spine,  214  , 

of  temporo-maxillary  joint,  223 

of  WTist,  223 

operative  treatment,  212 

pathology,  196 

polyarticular,  205 
■    symptoms,  202 

treatment,  208 

varieties,  205 
Arthritis,  dry,    196;   and  see  Arthritis  de- 
formans 

fibrosa,  206 

gonorrhoeal,  194 

infectious,  193,  206 

of  infants,  192 

proliferating,    196;    and   see   Arthritis 
deformans 

rheumatoid,  196;  and  see  Arthritis  de- 
formans 
Arthropathy,  neural,  259 

neuropathic,  259 

of  hip,  260 

of  vertebral  column,  260 

spinal,  259 

tabetic,  259 
Articular  tuberculosis,  i;   and  see  Tuber- 
culosis of  joints 
Articuli  dupHcati,  271;  and  see  Rickets 
Atrophic  spinal  paralysis,  acute,  406 
Atrophy,  in  tuberculous  disease  of  hip,  93, 
107 

in  tuberculous  disease  of  knee,  150 

unilateral,  476 
Attitude  in  rickets,  276 

in  tuberculous  disease  of  hip,  103 

in  tuberculous  disease  of  spine,  27 

of  rest,  284 

Bandy  legs,  296;   and  see  Bow-legs 
Bartlett's  machine  for  reducing  congenital 

dislocation  of  hip,  497 
Bechterew's  disease  of  spine,  214 
Bed-frame,  gas-pipe,  618 


INDEX. 


659 


Bone,  caries  of,  i 

changes  in,  in  rickets,  274 
syphilis  of,  252 
tuberculosis  of,  i 
tumors  of,  249 
Bow-legs,  296 

anterior  curvature  in,  297,  302 
apparatus  for,  637 
treatment,  305 
apparatus  for,  301,  635,  637 
causation,  297 
diagnosis,  299 
occurrence,  297 
osteoclasis,  302 
osteotomy,  304 
prognosis,  300 
symptoms,  297 
treatment,  300 

expectant,  300 
mechanical,  301 
operative,  302 
Brace  with  movable  shoulder-pieces,  639 
Brain,  operation  on,  in  spastic  paralysis,  457 
Buckminster  Brown's  splint  for  torticollis, 

400,  641 
Bunion,  594 
Bursae  of  hip,  243 

Bursitis  of  deep  prepatellar  bursa,  245 
of  hip,  243 
of  knee,  244 
of  shoulder,  246 
prepatellar,  244 

deep,  245 
post-calcaneal,  599 

Caliper  apparatus,  642 

splint,  161,  629 
Caput  obstipum,  392;   and  see  Torticollis 
Carcinoma  of  bone,  250 

of  spine,  250 
Caries  of  bone,  i 

of  spine,  16;  and  see  Tuberculous  dis- 
ease of  spine 
Cartilages,  loose,  231 
Casts  of  foot,  to  make,  580 
Casts  for  flat-foot  plates,  580 
Celluloid  bandages,  605 
Cerebellar  type  of  hereditary  ataxia,  465 
Cerebral    paralysis,    445;    and   see  Spastic 

paralysis 
Charcot's  disease  of  hip,  260 

joint  disease,  259 


Chest,  rhachitir,  275 
Chicken-breast,  389 
Children,  arthritis  deformans  in,  213 
Chondrodystrophia  ftxtalis,  282 
Chondroma  of  bone,  250 
Clawed  toes,  598 

Club-foot,  518;    and    see    Talipes    equino- 
varus 
acquired,  548 
non-deforming,  576 
paralytic,  548 
Club-hand,  556 
Cold  abscess  of  joints,  8 
Collum  distortum,  392;   and  see  Torticollis 
Congenital  dislocation  of  ankle,  515 
of  elbow,  515 
of  hip,  479 
of  knee,  512 
of  patella,  514 
of  shoulder,  515 
of  wrist,  516 
elevation  of  scapula,  391 
torticollis,  392 
Contracted  foot,  576 
Convalescent  hip  sphnt,  623 
Coxa  valga,  320 
Coxa  vara,  no,  308 

after-treatment,  320 
diagnosis,  314 
etiology,  308 
osteotomy  for,  318 
pathology,  309 
prognosis,  316 
splints,  316,  623,  627 
symptoms,  313 
traumatic,  311 

treatment,  320 
treatment,  316 
Coxalgia,  84;  and  see  Tuberculous  disease 

of  hip 
Coxitis,  84;  and  see  Tuberculous  disease  of 
hip 
senile,  218 
Craniotabes,  275 
Cubitus  valgus,  516 

varus,  516 
Cysts  of  knee,  240 

Degenerative     ataxia,     464;      and     see 

Hereditary  ataxia 
Dental    paralysis,    406;    and   see   Anterior 

poliomyelitis 


66o 


INDEX. 


Diffuse  muscular  lipomatosis,  458;   and  see 
Pseudo-hypertrophic  muscular  paralysis 
Dislocation  of  hip,  congenital,  479 
in  hip  disease,  85 
of  patella,  habitual,  246 
of  semilunar  cartilages,  236 
of  shoulder,  habitual,  248 
Dislocations,  congenital,  479 

from  infantile  paralysis,  419 
Distribution   of  chronic   tuberculous  joint 

disease,  11 
Dropsy  of  joint,  228 

Dr}'     arthritis,     196;     and     see     Arthritis 
deformans 

EcHiNOCoccrs  c3-sts  of  spine,  265 
Elbow,  congenital  dislocation  of,  515 

excision  of,  181 

synovitis  of,  243 

tennis,  243 

tuberculous  disease  of,  179 
Empyema  tuberculosum,  7 
Epiphyseal  disjunction,  311 
Equino-varus  splint,  646 
Erb's  type  of  muscular  atrophy,  463 
Essential  paralysis  of  children,  406 
Excision  for  anterior  poliomyelitis,  444 

of  ankle,  175 

of  elbow,  181 

of  hip,  137 

causes  of  death  in,  140 
functional  results,  141 
indications  for,  142 
mortality  of,  141 

of  knee,  166 

of  shoulder,  178 

of  wrist,  182 
Exostoses,  249 

bur  sate,  250 

cartilaginous,  250 

of  OS  calcis,  600 

of  tarsal  bones,  600 

False  tumor  albus,  254 

Family  ataxia,    464;    and   see    Hereditary 

ataxia 
Feet,  examination  of,  578 
Femur,  fracture  of  neck  of,  311 
infraction  of  neck  of,  311 
sarcoma  of,  252 
Fixation  treatment  of  tuberculous  disease  of 
hip,  116,  124 


Fixation  treatment  of  tuberculous  disease 

of  knee,  158,  163 
Flat-foot,  559 

causation,  569,  571  -^ 

diagnosis,  578 

differential  diagnosis,  579 

forcible  correction  of,  589 

pathology,  561 

plates  for,  580,  654 

prognosis,  580 

symptoms,  572 

tender  points  in,  574 

treatment,  580 

varieties,  569 
Flexed  toes,  598 
Floating  bodies  in  joints,  231 
Foetal  rickets,  282 
Foot,  anatomy  of  bones  of,  563 

casts  of,  to  make,  580 

in  infancy,  560 

normal,  560 

weakened,  566 
Fracture  in  tuberculous  disease  of  hip,  85 

of  neck  of  femiir,  311 
Fractures,  improperly  united,  treatment  of, 

3°7 
Friedreich's  disease,  464;   and  see  Heredi- 
tary ataxia 
Functional  affections  of  ankle,  472 
of  hip,  470 
of  joints,  467 

apparatus  for,  474,  638 
of  knee,  471 
of  spine,  469 
Funnel  breast,  390 

chest,  390 
Fungus  disease,  i 

Gant's  osteotomy  of  hip,  133 

Genu  extrorsum,  296;   and  see  Bow-legs 
introrsuni,  283;    and  see  Knock-knee 
valgum,  283;   and  see  Knock-knee 
varum,  296;    and  see  Bow-legs 

Genuclast,  165 

Gout,  254 

rheimiatic,    196;    and     see    Arthritis 
deformans 

Growing  pains,  263 

HAEMOPHILIA,  joint  lesions  in,  261 
Hallux  rigidus,  597 


INDEX. 


66 1 


Hallux  valgus,  593 

toe-post  for,  654 
varus,  597 
Hammer  toe,  597 
Harrison's  sulcus,  276 
Head  supports,  612,  613 

in  treatment  of  tuberculous  disease  of 
spine,  74 
Heberden's  nodes,  206 
Heel,  painful,  599 

policeman's,  599 
Hemiplegia,  spastic,  445;    and  see  Spastic 

paralysis 
Hereditary  ataxia,  464 

cerebellar  type,  465 
ataxic  paraplegia,  464 
Hey's  internal  derangement  of  knee,  236 

treatment,  239 
Hip,  arthritis  deformans  of,  217 
arthropathy  of,  260 
bursitis  of,  243 
Charcot's  disease  of,  260 
Hip,  congenital  dislocation  of,  1 10,  479 
accidents  in  treatment  of,  501 
after-treatment,  501 
diagnosis,  483 
differential  diagnosis,  485 
etiology,  479 
frequency  of,  479 
osteotomy  in,  507 
patholog}',  481 
prognosis,  487 

after-treatment,  508 
reduction    by   forcible    manipula- 
tion, 494 
by  open  incision,  489 
%vith  aid  of  mechanical  force, 

497 
relapses  in,  504 
symptoms,  483 
tenotomy  in,  499 
treatment,  488 

accidents  in,  501 
of  older  adult  cases,  511 
results  of,  504 
summary,  511 
varieties,  482 
Hip  disease,  84;   and  see  Tuberculous  dis- 
ease of  hip    . 
dislocation  of,  congenital,  479 

paralytic,  419 
excision  of,  137 


Hip,  functional  affection  of,  470 

inflammation,  acute  infectious,  of,  109 

malignant  disease  of,  252 

osteomyelitis  of,  109,  191 

ostitis,  chronic  articular,  of,  84;    and 
see  Tuberculous  disease  of  hip 

sarcoma  of,  iii 

sprains  of,  226 

syno\'itis  of,  108,  228 

tuberculous  disease  of,  84 
Hip-joint  disease,  84;  and  see  Tuberculous 

disease  of  hip 
Hip-splint,  convalescent,  623 

double  upright,  625 

Thomas,  625 

traction,  619 
Hollow  foot,  554;  and  see  Talipes  cavus 
Horse  heel,  548;  and  see  Talipes  equinus 
Housemaid's  knee,  244 
Hydrarthros,  228 
Hydrarthrosis,  228 
Hydrops  articulorum  chronicus,  228 
articulorum  tuberculosus,  7 

intermittent,  228 
Hypera;sthetic  spine,  51 
Hypertrophy  of  synovial  villi,  230 

unilateral,  476 
Hysterical  ankle,  472 

hip,  470 

joints,  467 

knee,  471 

spine,  51,  469 

Immobilization  and  ankylosis,  127 
Infantile  paralysis,  406;  and  see  Anterior 

poliomyeUtis 
Infants,  arthritis  of,  192 
Intermittent  hydrops,  228 

synovitis,  228 
Internal  derangement  of  knee.  236 
In-toe,  597 
Ischias  scoHotica,  342 

Jaw,  arthritis  of,  223 
Joint  affections  in  gout,  254 
in  haemophiUa,  261 
in  scurvy,  263 
in  syphihs,  252 
disease,  Charcot's,  259 
mice,  231 
Joints,  cold  abscess  of,  8 

functional  affections  of,  467 


662 


INDEX. 


Joints,  hysterical,  467 

inflammation  of,  193 

loose  bodies  in,  231 

nodosity  of,  196;  and  see  Arthritis  de- 
formans 

tuberculous  disease  of,  i 
Jury-mast,  59,  67 

Knee,  arthritis  deformans  of,  219 

bursitis  of,  244 

congenital  dislocation  of,  512 

cysts  of,  240 

dislocation    of     semilunar     cartilages, 
236 

forcible  flexion  of,  162 

functional  affection  of,  471 

housemaid's,  244 

hysterical,  471 

internal  derangement,  236 

lipoma  of,  235 

loose  bodies  in,  231 

pain  in,  in  hip  disease,  no 

purulent  or  fungous  synovitis  of,  147; 
and  see  Tuberculous  disease  of  knee 

scrofulous  disease  of,  147;  and  see  Tu- 
berculous disease  of  knee 

secondary  disturbance  of,  240 

sprains  of,  226 

synovitis  of,  147,  229 

trigger,  240 

tuberculous  disease  of,  147 

tumor    albus,    147;   and    see    Tuber- 
culous disease  of  knee 
Knees,  loose,  287 
Knee  spKnt,  jointed,  630 

Thomas,  627 
Knock -knee,  283 

brace  for,  292,  633 

diagnosis,  288 

etiology,  283 

gait  in,  287 

Macewen's  osteotomy  for,  293 

manipulation,  in  treatment,  290 

mechanical  production  of,  284 

occurrence,  283 

osteoclasis  for,  295 
results  of,  305 

osteotomy  for,  292 
results  of,  305 

paralytic,  289 

prognosis,  289 

symptoms    286 


Knock-knee,  traumatic,  289 
treatment,  289 

ambulatory,  292 
expectant,  289 
mechanical,  291 
operative,  292 
Kyphosis,  16;  and  see  Tuberculous  disease 
of  spine;    also  376,  and  see  Round 
shoulders 
apparatus  for,  382,  638,  639 
static,  from  occupation,  383 

I.AMINECTOilY,   82 

Landouzy-Dejerine  type  of  muscular  atro 

phy,  463 
Lateral  curvature  of  spine,  322 
cei-vical,  335 
curves  in,  336 

relative  frequency  of,  337 
deformity  in,  333 
diagnosis,  342 
displacement  of  abdominal  viscera  in, 

329 
distortion  of  pelvis  in,  328 
dorsal,  335 
etiology,  330 
examination,  342 
exercises  in,  357,  361 
frequency  of,  322 
in  ischias  scoliotica,  342 
jackets  for,  365 
limp  in,  336 
lumbar,  335 

methods  of  recording,  345 
pain  in,  332 
paralytic,  339 
pathology,  323 
plaster  jacket  for,  365 
prevention  of,  350 
prognosis,  348 
rhachitic,  338 
symptoms,  331 
tracings  of,  346 
treatment,  355 

corrective  measures,  360 

operative,  373 

postural,  355 
varieties  of,  338 
Wolff's  law,  325 
Lateral  deviation  of  spine  in  Pott's  disease, 

30 
Leather  splints  and  jackets,  606 


INDEX. 


663 


Lipoma  arborescens,  7,  235 

of  knee,  235 

solitarium,  235 
Lipomatous    muscular   atrophy,  458;    and 

see      Pseudo  -  hypertrophic     muscular 

paralysis 
Little's     disease,    445;     and     see    Spastic 

paralysis 
Loose  bodies  in  joints,  231 

knees,  287 
Lordosis,  384 

Lorenz  method  of  reducing  congenital  dis- 
location of  hip,  494 
Lumbar  abscess  in  Pott's  disease,  41 

Pott's  disease,  109 
diagnosis,  47 
operations  for,  79 

Macewen's  osteotomy  for  knock-knee,  293 
Mahdelung's  deformity  of  wrist,  516 
Malignant  disease  of  hip,  252 

of  spine,  51,  250 
Malpositions  of  limb,  in  tuberculous  disease 
of  hip,  94 
in  tuberculous  disease  of  knee,  152 
Malum  coxae  senile,  218 
Malum  senile,   196;  and  see   Arthritis  de- 
formans 
Malum  Pottii,  16;  and  see  Tuberculous  dis- 
ease of  spine 
Metatarsalgia,  591 

anterior,  591 
Morbus  anglicus,  271;   and  see  Rickets 
Morbus  coxae,  84;  and  see  Tuberculous  dis- 
ease of  hip 
senilis,  109 
coxarius,  84;  and  see  Tuberculous  dis- 
ease of  hip 
Morton's  disease,  591 
Movable  bodies  in  joints,  231 
Muscular  pseudo-hypertrophy,  458;  and  see 
Pseudo-hypertrophic  muscular  paralysis 
Myelitis  of  the  anterior  horns,  406 
Myogenic  paralysis,  406;    and  see  Anterior 

poliomyelitis 
Myopachynsis    lipomatosa,    458;    and    see 
Pseudo-hypertrophic  muscular  paralysis 
Myositis  ossificans,  265 

Nervous   system,   pathological    conditions 

of,  259 
Neural  arthropathy,  259 


Neuromimesis,  see  Functional  aflcctions  of 

joints,  467 
Neuromimetic  spine,  51 
Neuropathic  arthropathy,  259 

curvature  of  spinal  column,  214 
New    joints,    formation    of,    in    ankylosis, 

269 
Night  cries  in  hip  disease,  92,  107 

treatment  of,  131 
Nodes,  Heberden's,  206 
Nodosity  of  joints,    196;    and  see  Arthritis 

deformans 
Nodular  rheumatism,  196;  and  see  Arthritis 

deformans 
Non-deforming  club-foot,  576 

Obstetrical  paralysis,  465 
Orthopedic  surgery,  scope  of,  i 
Os  calcis,  exostosis  of,  600 
Osteoarthritis,  196;    and  see  Arthritis   de- 
formans of  spine,  214 
Osteoarthropathy    of    hereditary    syphilis, 

254 

secondary  hypertrophic,  263 
Osteochondritis  of  Parrot,  253 
Osteoclasis,  for  knock-knee,  295 

for  bow-legs,  302 
Osteoclast,  Rizzoli's,  302 
Osteomalacia,  280 

chronica  deformans  hypertrophica,  255 
Osteomyelitis,  infectious,  186 

diagnosis,  188 

differential  diagnosis,  188 

etiology,  186 

pathology,  187 

prognosis,  189 

symptoms,  188 

treatment,  189 
Osteomyelitis  of  hip,  109,  191 

of  spine,  190 
Osteotomy  for   anterior  poHomyelitis,  444 

for  bow-legs,  304 

for  congenital  dislocation  of  hip,  507 

for  coxa  vara,  318 

for  deformity  at  knee,  168 

for  knock-knee,  292 

for  tuberculous  disease  of  hip,  133 

for  tuberculous  disease  of  knee,  168 
Ostitis  deformans,  255 
Ostitis  of  hip,  chronic  articular,  84;  and  see 

Tuberculous  disease  of  hip 
Out-knee,  296;    and  see  Bow-legs 


664 


INDEX. 


Facet's  disease,  255 

Painful  heel,  599 

Palsy,    teething,    406;    and     see    Anterior 

poliomyelitis 
Paralysis,  acute  atrophic  spinal,  406 

cerebral,  445 ;  and  see  Spastic  paralysis 

dental,    406;    and  see    Anterior    poli- 
omyelitis 

essential,  of  children,  406 

infantile,  406;   and  see  Anterior  polio- 
myelitis 

in  Pott's  disease,  20,  37,  50,  81 

in  rickets,  274 

myogenic,  406;  and  see  Anterior  polio- 
myelitis 

obstetrical,  465 

pseudo-hypertrophic  muscular,  458 

regressive,  406;  and  see  Anterior  polio- 
myelitis 

spastic,  445 
Parrot's  disease,  253 
Patella,  congenital  absence  of,  514 
dislocation  of,  514 

dislocation  of,  habitual,  246 

slipping,  246 
Pectus  carinatum,  389 

excavatum,  390 

gallinatum,  389 
Periarthritis  of  shoulder,  242 
Periarticular  disease,  no 
Perineal  band,  120 
Pes  arcuatus,  554;  and  see  Talipes  cavus 

calcaneus,   551;   and  see  Talipes  cal- 
caneus 

cavus,  554;  and  see  Talipes  cavus 

contortus,  518;  and  see  TaHpes  equino- 
varus 

equinus,  548;  and  see  Talipes  equinus 

excavatus,  554;  and  see  Talipes  cavus 

planus,  572;  and  see  Flat-foot 

pronatus,  572;  and  see  Flat-foot 
Phelps'  operation  in  club-foot,  537 
Pigeon  breast,  389 

toe,  597 
Plantar  fascia,  division  of,  532 
Plaster  casts  of  foot,  to  make,  580 

jackets,  application  of,  58,  60,  63,  65, 
68 
removable,  67 
Plaster -of-Paris  bandages,  601 

splint,  125 
Podagra,  255 


Policeman's  heel,  599 
Poliomyelitis,  anterior,  406 
Porencephalus,  452 

Pott's  disease,    16;    and  see  Tuberculous 
■disease  of  spine 

support  for,  607 
Prepatellar  bursitis,  244 
Progressive  muscular  atrophy,  462 

types  of,  463 
Proliferating  arthritis,  196;  and  see  Arthritis 

deformans 
Protection  splint  in  hip  disease,  127 
Pseudoarthrosis,  192 

Pseudo-hypertrophic    muscular    paralysis, 
458 

attitude  in,  459 

diagnosis,  461 

etiology,  458 

mental  defect  in,  459 

pathology,  458 

prognosis,  462 

symptoms,  458 

talipes  equinus  in,  460 

treatment,  462 
Psoas  abscess,  39 

treatment,  80 

Quadrilateral  back  brace,  615 
viith  head  support,  617 

Railway  spine,  51 

Reel  foot,   518;   and  see  Talipes  equino- 

varus 
Regressive  paralysis,  406;  and  see  Anterior 

poliomyelitis 
Repair  of  tendons,  533 
Retropharyngeal  abscess,  41,  80 
Rhachitic  curves  in  upper  extremity,  307 
Rhachitis,  271;   and  see  Rickets 
Rheumatic  arthritis,  chronic,  196;    and  see 
Arthritis  deformans 
gout,  196;   and  see  Arthritis  deformans 
Rheumatism,   chronic  articular,    196;    and 
see  Arthritis  deformans 
gonorhoeal,  194 

nodular,    196;    and   see   Arthritis   de- 
formans 
Rheumatoid  arthritis,  196;  and  see  Arthritis 

deformans 
Rickets,  271 

adolescent,  273 
attitude  in,  276 


INDEX. 


665 


Rickets,  bone  changes  in,  274 

causation,  273 

chest  in,  275 

congenital,  283 

cranio  tabes  275 

diagnosis,  279 

differential  diagnosis,  279 

foetal,  282 

Harrison's  sulcus,  276 

late,  273 

latent,  283 

occurrence,  272 

paralysis  of,  274 

pathology,  271 

pelvic  deformity  in,  277 

prognosis,  279 

rosary,  275 

spine  in,  276 

symptoms,  274 

treatment,  280 
Rigidity  of  spine,  214 
Rizzoli's  osteoclast,  302 
Rosary  in  rickets,  275 
Rotary    lateral    curvature,    322;    and    see 

Lateral  curvature  of  spine 
Round  shoulders,  377 

apparatus  for,  382,  638,  639 

treatment,  379 
Rupture  of  spinal  ligaments,  226 


Sacro-iliac  disease,  183 
Sacro-coxalgia,  183 
Sacro-coxitis,  183 
Sarcoma  of  bone,  250 

of  femur,  252 

of  hip.  III 

of  spine,  250 
Scapula,  congenital  elevation  of,  391 
School  seats,  351 

Scoliosis,  322,  333;   and  see  Lateral  curva- 
ture of  spine 

ischiatica,  342 

neuromuscularis,  342 

neuropathica,  342 
Scrofulous  disease,  i 

of  knee,  147;  and  see  Tuberculous  dis- 
ease of  knee 
Scurvy,  joint  affections  in,  263 
Semilunar  cartilages,  dislocation  of,   236 

treatment,  239 
Senile  coxitis,  218 


Shortening  in  tuberculous  disease  of  hip, 

97.  103.  136 

in  tuberculous  disease  of  knee,  150 
Shoulder,  arthritis  deformans  of,  222 

bursitis  of,  246 

congenital  dislocation  of,  515 

excision  of,  178 

habitual  dislocation  of,  248 

obstetrical  paralysis  of,  465 

periarthritis  of,  242 

synovitis  of,  241 

tenosynovitis  of,  242 

tuberculous  disease  of,  176 
Spastic  hemiplegia,   445;   and    see  Spastic 

paralysis 
Spastic  paralysis,  445 

after-treatment,  456 

atrophy  in,  447 

condition  of  muscles  in,  448 

contractures  in,  447 

diagnosis,  453 

etiology,  451 

mental  defects  in,  447 

operations  upon  brain  for,  457 

pathology,  451 

prognosis,  453 

symptoms,  445 

tendon  transferrence  for,  457 

treatment,  454 

operative,  455 
Spinal  arthropathy,  259,  260 

column,  neuropathic  curvature  of,  214 

curvature,    16;    and    see   Tuberculous 
disease  of  spine 

ligaments,  rupture  of,  226 

paralysis,  acute  atrophic,  406 
Spine,  actinomycosis  of,  264 

angular  curvature  of,  16;  and  see  Tu- 
berculous disease  of  spine 

ankylosing  inflammation  of,  214;  and 
see  Spondylitis  deformans 

arthritis  deformans  of,  214 

Bechterew's  disease  of,  214 

carcinoma  of,  250 

caries  of,  16;  and  see  Tuberculous  dis- 
ease of  spine 

echinococcus  cysts  of,  265 

functional  affection  of,  469 

hypera'sthetic,  51 

hysterical,  51,  469 

irritable,  469 

lateral  curvature  of,  322 


666 


INDEX. 


Spine,  malignant  disease  of,  51,  250 

neuromimetic,  51 

osteoarthritis  of,  214 

osteomyelitis  of,  190 

railway,  51 

rigidity  of,  214 

sarcoma  of,  250 

spondylitis  deformans  of,  214 

sprains  of,  225,  470 

syphilis  of,  254 

tuberculosis  of,  16 

typhoid,  191 

variations  in  length  of,  375 
Splay-foot,  572;  and  see  Flat-foot 
Spondylitis,  16;  and  see  Tuberculous  dis- 
ease of  spine 

deformans,  214 
.  traumatic,  226 
Spondylolisthesis,  385 
Sprains,  224 

of  ankle,  227 

of  back,  50 

of  hip,  226,  228 

of  knee,  226 

of  spine,  225,  470 

of  wrist,  227 
Sprengel's  deformity,  391 
Spurious  valgus,  572;  and  see  Flat-foot 
Strumous  disease,  i 
Subluxation  of  wrist,  spontaneous,  516 
Symphysis  pubis,  relaxation  of,  249 
Synovial  villi,  hypertrophy  of,  230 
Synovitis,  arborescent  tuberculous,  7 

chronic,  228 

intermittent,  228 
serous,  228 

gonorrhceal,  194 

infectious,  193 

of  ankle,  240 

of  elbow,  243 

of  hip,  108,  228 

of  knee,  229 

purulent  or  fungous,  147;  and  see 
Tuberculous  disease  of  knee 

of  shoulder,  241 

of  tendo  Achillis,  600 

of  wrist,  243 

purulent  or  fungous,  of  knee,  147;  and 
see  Tuberculous  disease  of  knee 
Syphilis  and  rickets,  274 

of  bone,  252 

of  spine,  254 


Tabetic  arthropathy,  259 
Tables  of  height  and  weight,  349 
Talipes,  518 

calcaneus,  551  ^  ' 

apparatus  for,  651 
cavus,  554 
equino-varus,  518 
acquired,  548 
apparatus  for,  529,  646 
diagnosis,  523 
etiology,  522 

forcible  manipulation,  537 
frequency,  518 
manual  manipulation,  526 
mechanical  correction,  526 

summary  of,  537 
operative  treatment,  530,  537 
osteotomy,  540 
pathology,  519 
Phelps'  operation,  537 
plantar  fascia,  division  of,  532 
plaster-of-Paris  bandages,  527 
prognosis,  524 
relapses,  545 
splint  for,  646 
symptoms,  522 
tenotomy,  530 
treatment,  525 

generalization,  547 
equinus,  548 

apparatus  for,  551,  649,  650 
valgus,  552 

apparatus  for,  651 
varus,  554 

apparatus  for,  651 
Tarsal  bones,  exostoses  of,  600 
Teething    palsy,    406;    and    see    Anterior 

poliomyelitis 
Tempered  steel  uprights,  638 
Temporo-maxillary  joint,  arthritis  deform- 
ans of,  223 
Tendo  Achillis,  synovitis  of,  600 

tenotomy  of,  530 
Tendon  transferrence  in  spastic  paralysis, 

457 
transplantation  in  anterior  poliomye- 
litis, 439 
Tendons,  divided,  repair  of,  533 
Tennis  elbow,  243 
Tenosynovitis  of  ankle,  241 
of  shoulder,  242 
of  wrist,  243 


INDEX. 


667 


Tenotomy  in  congenital  dislocation  of  hip, 

499 

in  spastic  paralysis,  455 

of  tendo  Achillis,  530 
Thomas  caliper  splint,  629 

collar,  615 

hip  splint,  126,  625 

knee  splint,  159,  627 
Thorax,  deformities  of,  389,  390 
Tibia,  lesions  of  tubercle  of,  226 
Toe-post,  654 
Toes,  contraction  of,  598 
Tophi,  255 
Torticollis,  392 

acquired,  393 

apparatus  for,  400,  641 

brace,  641 

Buckminster  Brown's  splint,  400,  641 

congenital,  392 

diagnosis,  397 

etiology,  392 

pathology,  394 

physiological,  393 

posterior,  398 

treatment,  403 

prognosis,  398 

spasmodic,  394         < 
treatment,  403 

symptoms,  395 

treatment,  399 

operative,  400 
Traction  hip  splint,  619 

in  hip  disease,  116,  120,  124,  131 

in  knee-joint  disease,  162 
Traumatic  coxa  vara,  311 

spondylitis,  226 
Trigger  knee,  240 

Tuberculin,  as  a  diagnostic  method  in  tu- 
berculosis of  joints,  12 
Tuberculosis,    articular    i  ;     and    see   Tu- 
berculous disease  of  joints 

of  bone,  i 

of  vertebrae,  16;  and  see  Tuberculous 
disease  of  spine 
Tuberculous  disease  of  ankle,  171 

diagnosis,  173 

excision,  175 

fixation  brace,  173,  632 

mechanical  treatment,  173 

operative  treatment,  175 

prognosis,  173 

symptoiris,  171 


Tuberculous  disease  of  elbow,  179 
excision  of,  181 
symptoms,  179 
treatment,  180 
Tuberculous  disease  of  hip,  84 
abduction  in,  104 
abscess  in,  86,  96,  115 

treatment  of,  130 
acetabular,  84 
adduction  in,  104 
after-treatment,  136 
ambulatory  treatment  in,  124 
amputation  for,  144 
ankylosis  in,  127 
atrophy  in,  93,  107,  115 
attitudes  in,  94,  103 
bed -frame  for,  117,  618 
cause  of  death,  11 1 
clinical  history,  88 
complications,  treatment  of,  131 
convalescence,  treatment  during    127 
convalescent  spKnt,  623 
course  of  disease,  89 
crutches  in,  123 
curetting  and  drainage  in,  137 
deformity  in,  114 

treatment  of,  131 
diagnosis,  99 
differential  diagnosis,  108 
dislocation  in,  85 
distortion,  114 
double,  99,  136 
duration  of  treatment,  113 
early  symptoms,  88 
examination  in,  100 
excision,  137 

results  of,  140 
fixation,  116 

splints,  124 
flexion,  106 
fracture  in,  85 
functional  results,  112 
general  condition  in,  98 
hysterical,  no 
immobilization  in,  127 
lameness  in,  90,  102 
leather  splints,  124,  606 
limping  in,  88,  102 
malposition  of  limb  in,  94 
measurements  in,  104 
modified  traction  splints,  124 
mortality,  in 


668 


INDEX. 


Tuberculous  disease  of  hip,  muscular  fixa- 
tion in,  92,  100 

spasm  in,  02,  100 
night-cries  in,  92,  107 

treatment,  131 
operative  treatment,  137 
osteotomy,  133 
pain  in,  89,  90,  107,  no 
pathology,  84 
periarticular  symptoms,  95 
perineal  bands,  120 
plaster-of-Paris  splint  in,  125 
plaster  bandage,  124,  601 
prognosis,  in 

protection  splints  in,  127,  623 
recovery,  112 
relapses,  129 
remissions  in,  98 

separation  of  ephiphyses  in,  85,  in 
shortening  in,  97,  103,  114,  136 
summary  of  treatment,  145 
swelling  in,  107 
symptoms,  88 
temperature,  99 

Thomas  spHnt  in,  124,  126,  625 
traction,  116 

splint  in,  119,   123,   124,  619 

straps  in,  120 
treatment,  115 

of  complications,  130 

operative,  137 

principles  of,  by  fixation  and  trac- 
tion, 116 

summary  of,  145 

of  mechanical,  130 

termination,  129 
Tuberculous  disease  of  joints,  i 
diagnosis,  12 
etiology,  9 
distribution  of,  11 
origin,  4 
prognosis,  12 
pathology,  i 
process  of  repair,  6 
terminations,  4 
treatment,  13 

general,  13 

local,  14 
Tuberculous  disease  of  knee,  147 
abscess  in,  153 

treatment,  166 
amputation  for,  169 


Tuberculous    disease   of    knee,    ankylosis, 
168 
arthrectomy,  168 
atrophy  in,  150 
caliper  splint,  161,  629 
clinical  history,  148 
complications,  treatment  of,  161 
deformity,  152 

treatment,  161 
diagnosis,  154 
differential  diagnosis,  154 
dislocation  in,  152 
erasion,  168 
excision,  166 
fixation,  158,  163 

-   bandages  in,  163 
forcible  reduction  in,  163 
genuclast,  165 
lameness,  152 
muscular  fixation,  152 
osteotomy  in,  168 
pain,  151 
pathology,  147 
prognosis,  156 
protective  splint,  159 
rotation  of  tibia,  153 
shortening  in,  150 
swelling  in,  149 
symptoms,  149 
Thomas  splint,  159,  627 
traction  in,  162 
splint,  630 
treatment,  157 
Tuberculous  disease  of  sacro-iliac  joint,  183 

of  shoulder,  176 
Tuberculous  disease  of  spine,  16 
abscess  in,  19,  39 
diagnosis  of,  49 
treatment  of,  79 
ambulatory  treatment,  57 
antero-posterior  support,  68,  607 
apparatus  for  correction,  69,  607 
attitude  in,  27,  44 
bed-frame  for,  54,  618 
Calot's  reduction,  77 
cardiac  and  vascular  changes  in,  22 
celluloid  bandages,  605 
cervical,  45 

abscess,  41 
operations  for,  78 
chest  in,  36 
collars,  75,  615 


INDEX. 


669 


Tuberculous    disease    of    spine,  complica- 
tions, 37 
corsets,  605,  606 
deformity,  22,  33,  36 

correction  of,  77 

tracings  of,  34,  37,  70,  71 
diagnosis,  43 

of  abscess  in,  49 

of  paralysis  in,  50 
dorsal,  47 

abscess,  41       ■ 
etiology,  23,  25 
examination,  43 
eye  symptoms,  32 
forcible  correction,  77 
gait  in,  44 

general  condition,  37 
head  supports  in,  74,  612,  613,  615 

traction  in,  56 
history,  16 

jury-masts  for,  59,  67 
laminectomy  in,  82 
lateral  deviation  in,  30 
leather  jackets,  606 
localization,  24 
lumbar,  47,  109 

abscess  in,  41 

diagnosis  of,  47 
mortality,  53 
muscular  stiffness  in,  44 
occurrence,  23 
pain  in,  31 
paper  jackets,  60 
paralysis  in,  37 

diagnosis  of,  50 

pathology,  20 

treatment,  81 
pathology,  16 
plaster  jackets,  57,  601 
prognosis,  52 
psoas  abscess,  39 

treatment,  80 
psoas  contraction,  30,  48 

treatment,  80 
recumbency-treatment,  54 
removable  jackets,  67 
retardation  of  growth  in,  35 
retropharyngeal  abscess,  41,  80 


Tuberculous  disease  of  spine,  spontaneous 
cure  in,  34 
suspension  in,  58 
summary  of  treatment,  82 
symptoms,  25 
temperature  in,  36 
Thomas  collar,  614 
tracings  of  deformity,  34,  37,  70,  71 
traction  in,  56 
treatment,  54 

ambulatory,  57 
apparatus  for,  69,  607 
by  collars,  75 
by  forcible  correction,  77 
by  head  supports,  74 
by  plaster  jackets,  57,  601 
by  recumbency,  54 
by  steel  appliances,  69 
operative  measures,  78 
selection  of  method,  76 
summary  of,  82 
Tuberculous  disease  of  wrist,  182 
Tuberculous  nodules,  solitary,  7 
Tumor  albus,  147;  and  see  Tuberculous  dis- 
ease of  knee 
false,  254 
Tumors  of  bone,  249 
Typhoid  spine,  191 

Unilateral  atrophy  and  hypertrophy,  476 

VertebR/E,  tuberculosis  of,   16;    and  see 
Tuberculous  disease  of  spine 

Weak  foot,  566 

White  swelhng,  147;  and  see  Tuberculous 

disease  of  knee 
Wolff's  law,  325 
Wrist,  arthritis  deformans  of,  223 

congenital  dislocation  of,  516 

spontaneous  subluxation  of,  516 

excision  of,  182 

Mahdelung's  deformity  of,  516 

sprains  of,  227 

synovitis  of,  243 

tenosynovitis  of,  243 

tuberculous  disease  of,  182 
Wry-neck,  392;   and  see  Torticollis 


KDl^i 


31ZII 


Orthopedic  surgery 


2002313820 


